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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610162
Report Date: 04/25/2022
Date Signed: 04/25/2022 12:47:09 PM

Substantiated


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
03/29/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220329164326
FACILITY NAME:LOVE & CARE SENIOR LIVING, INC.FACILITY NUMBER:
197610162
ADMINISTRATOR:PASCO, DINAH RFACILITY TYPE:
740
ADDRESS:17710 MARTHA STREETTELEPHONE:
(818) 585-0063
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:6CENSUS: DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Uncleared adult providing care to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Administrator, Dinah Pasco, and explained the reason for the visit. LPA conducted a physical plant tour at 10:00am.

--- Uncleared adult providing care to residents.
It was alleged that residents reported that an uncleared adult, who identified as the owner, helped them get settled and visits the facility periodically. To investigate this allegation, on 04/01/2022 at 11:00am, LPA interviewed the Administrator, residents and other parties. Based on the interviews, it was determined that the uncleared adult was witnessed in the facility by residents and identified as “the boss” by a staff member which proves that the uncleared adult was acting in the capacity of an employee of the facility. Furthermore, per the facility’s administrator, the uncleared adult “drops off hospice supplies as needed”.

(CONT. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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 3
Control Number 31-AS-20220329164326
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: LOVE & CARE SENIOR LIVING, INC.
FACILITY NUMBER: 197610162
VISIT DATE: 04/25/2022
NARRATIVE
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Based on the information revealed during the interviews, the allegation is SUBSTANTIATED at this time.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report, LIC 9099-D, LIC 421 and Appeal Rights were discussed and provided to the Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220329164326
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: LOVE & CARE SENIOR LIVING, INC.
FACILITY NUMBER: 197610162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
87355(e)
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87355 Criminal Record Clearance: (e) All
individuals ... shall prior to working,.. in a
licensed facility: (1) Obtain a California
clearance.. as required by the Department

This requirement is not met as evidenced by:
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The Administrator will review Section 87355 and will inform in writing explaining how they will assure to follow Title 22 Regulations with regards to allowing uncleared adults into the facility.
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Based on interviews, the licensee did not
comply with the section cited above as
the facility allowed an uncleared adult to
provide a service without obtaining clearance which poses a potential Health, Safety or Personal Rights 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3