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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610166
Report Date: 02/22/2024
Date Signed: 05/03/2024 09:54:44 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/14/2023 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20231214102926
FACILITY NAME:QUARTZ HAVENFACILITY NUMBER:
197610166
ADMINISTRATOR:AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:7250 QUARTZ AVETELEPHONE:
(626) 373-4386
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 4DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dunhill Tolentino, House ManagerTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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9
Staff did not ensure that residents were provided with activities
INVESTIGATION FINDINGS:
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13
This is an amendment to the original report on 02/22/2024, to correct/replace pages that were created in error.
At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to deliver final findings. LPA met with the House Manger, Dunhill Tolentino, and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial complaint visit on 12/21/2023, interviews and record reviews were made. At 10:18 am, LPA requested resident, staff roster, and Administrator's certificate. At 10:30 am, LPA requested copies of pertinent information which include, but not limited to facility infection control plan, food services trainings, activities list, physician's report, appriasal needs and services plan, and etc. relevant to the investigation. At approximately 10:45 am, LPA conducted a physical plant tour with Licensee. Between 11:00am – 1:00 pm, LPA interviewed the Licensee, one (1) staff and four (4) out of five (5) residents, who were able to communicate. Continue on LIC 9099C


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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 5
Control Number 31-AS-20231214102926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: QUARTZ HAVEN
FACILITY NUMBER: 197610166
VISIT DATE: 02/22/2024
NARRATIVE
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Staff did not ensure that residents were provided with activities

It is alleged that the staff did not provide residents with activities. LPA conducted interviews with four (4) out of five (5) residents who are able to communicate, Licensee and one (1) staff member, and as well as LPA’s observation at the time of the visit to ensure activities are being held. Information from interviews revealed that since the onset of Covid-19 the facility activities routine changed. Interviews with residents did not show that the facility conducts bingo, exercise, coloring, music, etc. Interview with Licensee and staff revealed that the facility does not provide or offer that many activities since the residents do not seem interested in doing anything. During the initial visit between 9:45 AM to 3:00 PM, LPA did not observe any activities being offered to residents in care. Based on the information obtained through interviews and observation this allegation is deemed to be SUBSTANTIATED at this time.

Deficiencies issued per Title 22.

Exit interview conducted appeal rights explained and copy of this report signed and delivered

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/14/2023 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20231214102926

FACILITY NAME:QUARTZ HAVENFACILITY NUMBER:
197610166
ADMINISTRATOR:AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:7250 QUARTZ AVETELEPHONE:
(626) 373-4386
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 4DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dunhill Tolentino, House ManagerTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff made inappropriate comments about resident while in resident’s presence

Staff prepared resident meals in an unsanitary manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amendment to the original report on 02/22/2024, to correct/replace pages that were created in error.
At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to deliver final findings. LPA met with the House Manger, Dunhill Tolentino, and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial complaint visit on 12/21/2023, interviews and record reviews were made. At 10:18 am, LPA requested resident, staff roster, and Administrator's certificate. At 10:30 am, LPA requested copies of pertinent information which include, but not limited to facility infection control plan, food services trainings, activities list, physician's report, appriasal needs and services plan, and etc. relevant to the investigation. At approximately 10:45 am, LPA conducted a physical plant tour with Licensee. Between 11:00am – 1:00 pm, LPA interviewed the Licensee, one (1) staff and four (4) out of five (5) residents, who were able to communicate. Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20231214102926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: QUARTZ HAVEN
FACILITY NUMBER: 197610166
VISIT DATE: 02/22/2024
NARRATIVE
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Staff made inappropriate comments about resident while in resident’s presence
To investigate this allegation, LPA conducted an interview with the Licensee and staff # 1 (S1) and was informed that the staff always takes care of all residents with dignity and respect. LPA was also informed that facility conducts monthly meetings with all staff regarding the basic services, personal rights, mandated reporter, ect. LPA conducted review of all training documents and confirmed the training is being conducted and completed. In addition, four (4) out of five (5) interviewed residents that the facility staff always treats them with respect and they do not have any concerns regarding this allegation. Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

Staff prepared resident meals in an unsanitary manner

To investigate this allegation, LPA reviewed the infection control plan and toured the facility kitchen. The kitchen was clean and sanitary. LPA conducted interviews with four (4) out of five (5) residents, one (1) staff, and the Licensee. Residents interview confirmed that the food is always clean and sanitary. They never witnessed food being prepared in unsanitary manner. Staff and Licensee interview confirmed that they always prepare food in a sanitary manner. LPA was able to observe the end of breakfast and lunch being served during the visit on 12/21/2023. LPA observed that (S1) is wearing gloves and a mask while prepare and serve food to residents. Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20231214102926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: QUARTZ HAVEN
FACILITY NUMBER: 197610166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
CCR
87219(a)(i)
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Planned activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation.......activities. The activities:
(i) facilities shall provide sufficient equipment and supplies.....
This requirement is not met as evidenced by:
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 Licensee shall maintain a log of all the planned activities that have been completed and offered by staff that also documents the residents who have participate in the activities or do not wish to participate.
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Based on LPAs observation and staff interview, the licensee did not comply with the section cited above by not providing or offering activities to residents in care which poses/posed a potential health, safety to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5