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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610247
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:38:16 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.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
11/15/2024 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20241115122956
FACILITY NAME:PHIBA HOMEFACILITY NUMBER:
197610247
ADMINISTRATOR:KAWOOYA, DAVIDFACILITY TYPE:
735
ADDRESS:20112 LANARK STTELEPHONE:
(818) 617-0594
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:4CENSUS: 4DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rita Nabukenya-CaregiverTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff yells at residents.
INVESTIGATION FINDINGS:
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On 11/21/2024 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced 10-day complaint visit at this facility to investigate the above allegation. LPA met with the Caregiver Rita Nabukenya who granted access to the facility, entrance interview conducted. Shortly after Licensee/Co-Administrator Amanya Herbert arrived and LPA diclosed the purpose of the visit.

LPA requested resident and staff rosters, files and potential documents relevant to the investigation. At approximately 12:00pm, LPA conducted a physical plant walk through to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. LPA did not observe any immediate health and safety issues during the visit.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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-20241115122956
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: PHIBA HOME
FACILITY NUMBER: 197610247
VISIT DATE: 11/21/2024
NARRATIVE
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Allegation: Staff yells at residents in care.

It was reported that staff does not treat clients with respect and yells at them. Interview with the Licensee/Co-Administrator revealed that all staff members working at this facility are well aware of four (4) out of four (4) client's medical conditions and that they would never yell at any of the clients. LPA was able to speak with two (2) staff at the facility: staff interviewed denied ever hearing any staff member speak inappropriately and/or yell at any of the clients. The Administrator and Staff members denied and stated that they never had an employee by the name "Clark".

LPA was able to interview one (1) out of four (4) clients, due to clients were not present at the time of the visit and were attending the day programs. Interview with Client #1 (C1) also indicated and denied four (4) out four (4) clients ever being yelled at or staff speaking to clients in an inappropriate manner. The Client (C1) was unable to identify and stated never seen or heard staff member named "Clark".

Based on information obtained through interviews, document review and LPA's observation this allegation is deemed Unsubstantiated.

Exit interview conducted and copy of report was provided to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2