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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 07/08/2021
Date Signed: 07/08/2021 11:29:45 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2021 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210628114449
FACILITY NAME:VELVET CAREFACILITY NUMBER:
197610143
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:15731 LEMARSH ST.TELEPHONE:
(818) 891-9186
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
07/08/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff lock residents in facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced complaint visit. LPA met with facility staff and explained the reason for this visit. LPA spoke with administrator by phone, who arrived too the facility shortly after. The following was determined:

It is alleged that that staff lock residents in the facility. During today’s visit, from 930am to 1145am, LPA conducted a physical plant inspection, and interviewed the Administrator. It was revealed to LPA, that the Administrator was not aware that a former employee was inserting a nail in the door frame at the bottom of the front door, in order to secure residents inside. The Administrator discussed with the employee, and other staff, that was not safe, and to remove the nail from the door. LPA was able to visually see the hole in the door frame; but it was not observed during today’s visit. This poses as a potential health and safety risk to residents in care. Therefore, based on the interview conducted with the Administrator, the allegation “Staff lock residents in the facility”, is SUBSTANTIATED.
Exit interview conducted, appeal rights, and copy of report provided
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20210628114449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2021
Section Cited
CCR
80072(a)(7)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night. This requirement was not met, evidenced by: during today's visit, LPA was informed that
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Administrator removed the nail, and had a discussion with staff, and will have a repair fix the whole in the door. POC is cleared during today's visit.
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a previous employee was placing a nail inside
the door frame of the front door, in order to secure residents. The Administrator was not aware, but informed all staff to remove the nail and that was a safety issue. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2