<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610205
Report Date: 11/13/2024
Date Signed: 11/18/2024 03:05:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
11/07/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20241107085345
FACILITY NAME:HUMBLE HAVEN RCFE IIIFACILITY NUMBER:
197610205
ADMINISTRATOR:DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:38433 ANSET DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: DATE:
11/13/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Raquel Adriano & Tatiana BuendiaTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff used inappropriate locks on the facility grounds
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended copy of the report previously issued on 11/13/2024. This report supersedes reports previously issued. The findings for this complaint remain the same.

On November 13, 2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a complaint investigation at the above facility to address the following allegation(s).

LPA Spaeth was met by two caregivers. LPA Spaeth spoke to the Licensee, Nicole De Las Alas via phone call. LPA explained the purpose of this visit was to investigate the complaint and present findings.

Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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 2
Control Number 31-AS-20241107085345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HUMBLE HAVEN RCFE III
FACILITY NUMBER: 197610205
VISIT DATE: 11/13/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This is an amended copy of the report previously issued on 8/14/2024. This report supersedes reports previously issued. The findings for this complaint remain the same.

LPA toured the facility at 10:45 am until 11:10 am. LPA interviewed five (R1-R5) out of six residents at 11:10 am until 12:15 pm. A resident (R6) was unavailable. LPA Spaeth interviewed two staff members (S1-S2) out of the four staff members at 12:30 pm until 12:55 pm.

Regarding the allegation: Staff used inappropriate locks on the facility grounds. It’s being alleged a hotel style lock is used on the top of the door in addition to a regular lock. During LPA’s tour, LPA observed only a single lock on the front door.

R1-R5 unanimously confirmed they are able to leave the facility through the front door without any issues. S1-S2 confirmed the residents are not hindered from leaving the facility through the front door.

Based upon resident and staff interviews, the allegation is unsubstantiated.

Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2