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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610237
Report Date: 05/14/2023
Date Signed: 05/14/2023 03:31:38 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
09/19/2022 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20220919123009
FACILITY NAME:ABAD CARE HOMESFACILITY NUMBER:
197610237
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:20128 DEVONSHIRE STTELEPHONE:
(747) 237-0417
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 4DATE:
05/14/2023
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Mylin Olivas - AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff spoke inappropriately to other staff in the presence of resident(s) in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA initially met with staff Pauline Fiesta who called the administrator and explained the reason for the visit. Administrator arrived 30 minutes later.

LPA conducted physical plant tour at 10:35 AM, requested copy of facility documents relevant to the investigation at 11:00 AM and interviewed staff and residents between 11:15 AM to 2:30 PM. It was alleged that Staff #1 (S1) told Staff #2 (S2) to poison Staff #3 (S3). LPA's interview with five (5) staff today between 11:15 AM to 2:30 PM, revealed that the there was no incident in the facility wherein S1 told S2 to poison S3. LPA's interview with four (4) residents today between 11:15 AM to 2:30 PM revealed that no one among the four (4) residents experienced nor witness any staff mistreated or talk inappropriately to any resident. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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