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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610237
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:43:58 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
10/17/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20241017160918
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: 5DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Myline Olivas, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff did not respond to resident in a timely manner.
INVESTIGATION FINDINGS:
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At 09:55am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with the Administrator and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:00am, LPAs requested resident and staff roster. At 10:05am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Client/Resident Personal Property and Valuables, relevant to the investigation. At approximately 10:10am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:15am – 12:30pm, LPAs interviewed the Administrator, two (2) staff, and four (4) out of five (5) residents.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 6
Control Number 31-AS-20241017160918
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: ABAD CARE HOMES
FACILITY NUMBER: 197610237
VISIT DATE: 10/23/2024
NARRATIVE
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Allegation: Staff did not respond to resident in a timely manner

It was alleged that on 9/10/2024, at about 2:30 or 3:00 AM, R1 could not breath and called the staff and no one responded for about 15-minutes. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that when an incident occurs with the resident, the staff must immediately call 911 and then notify the Administrator. Interview with S1 revealed that R1 was periodically checked on a day of an incident. LPAs were also informed that last time R1 was checked on was at 12:30am and S1 started a laundry, which is located in the garage. S1 confirmed that due to the washer and dryer noise, S1 did not hear R1 calling for help (around 2:30-3:00am), therefore, S1 provided help 15-minutes later. S1 also confirmed that the Administrator was immediately contacted and the Administrator instructed S1 to hang up and call 911. Based on interviews and information gathered, during today's visit, this allegation is Substantiated.

Deficiency cited on LIC9099-D


Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/17/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20241017160918

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: 5DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Myline Olivas, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff did not meet the needs of resident in care.
Staff are not providing activities for residents.
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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3
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5
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7
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13
At 09:55am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with the Administrator and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:00am, LPAs requested resident and staff roster. At 10:05am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Client/Resident Personal Property and Valuables, relevant to the investigation. At approximately 10:10am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:15am – 12:30pm, LPAs interviewed the Administrator, two (2) staff, and four (4) out of five (5) residents.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 6
Control Number 31-AS-20241017160918
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: ABAD CARE HOMES
FACILITY NUMBER: 197610237
VISIT DATE: 10/23/2024
NARRATIVE
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Allegation: Staff did not meet the needs of resident in care.

It was alleged that reported that a couple of days after returning from the hospital R1 was in bed and was covered in ants and the staff denied to bath R1. To investigate this allegation, LPAs conducted an interview with the Administrator and two (2) staff members and all parties interviewed informed LPAs that R1 was never observed to be covered in ants. LPAs were also informed that R1 often refused showers. Moreover, interview with four (4) out of five (5) residents, expressed no concerns regarding this allegation. Therefore, based on interviews and information gathered, this allegation is deemed, Unsubstantiated.

Allegation: Staff are not providing activities for residents.

It was alleged that R1 and the other residents are not provided with any activities. To investigate this allegation, LPAs conducted an interview with the Administrator and two (2) staff members and all parties interviewed informed LPAs that every morning, during the breakfast time, the staff encourage residents to participate in a different activities, such as outside walks, puzzles, bingo, karaoke, books and other games. LPAs were informed that most residents chose not to participate in a group activities. Moreover, Administrator informed LPAs that all residents were enrolled in a Day Program. However, two (2) residents refused the services and preferred to stay at the facility. In addition, interviews conducted with residents confirmed that they rather do individual activities; like read a book or watch TV, than participate in group activities. Therefore, based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Allegation: Staff did not safeguard resident's personal belongings.

It was alleged that on 9/16/2024, R1 was removed from this facility and some of his/her clothes were missing. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that R1 was admitted to this facility on 09/08/24 and relocated on 09/16/24. The Administrator informed LPAs that although no "in advance" notification verbal/written was provided regarding R1's relocation, R1's property and valuables were inventoried and signed by R1's family member upon departure. Moreover, four (4) out of five (5) residents interviewed expressed no concerns regarding this allegation. Based on interviews and record reviews, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20241017160918
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: ABAD CARE HOMES
FACILITY NUMBER: 197610237
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87469(c)(1)
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(c) If a resident... experiences a medical emergency, facility staff shall do one of the following: (1) Immediately telephone 9-1-1... and identify the resident as the person to whom the order refers.
This requirement is not met as evidenced by:
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Licensee/Administrator will provide an in-service training to all staff. Copy of training will be submitted to LPA.
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Based on LPAs inspection the licensee did not comply with the section cited above. Staff did not respond to R1's call in a timely manner, which poses/posed a potential health and safety risk 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6