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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610252
Report Date: 08/27/2024
Date Signed: 10/04/2024 01:25:41 PM

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
08/19/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240819162154
FACILITY NAME:FORBES HOMEFACILITY NUMBER:
197610252
ADMINISTRATOR:LUCKY JAY PANAFACILITY TYPE:
735
ADDRESS:9608 FORBES AVE.TELEPHONE:
(626) 926-7186
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lora May PanaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not prevent a resident from disturbing other residents.
INVESTIGATION FINDINGS:
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This is an amended copy of the report previously issued on 8.27.2024. After review of this complaint, it was determined corrections of the deficiency type needs to be change from Type A to Type B.

On 8.27.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conducted an unannounced visit to investigate the above allegation. LPA was greeted by facility staff Lora May Pana who is the designee and LPA explained the reason for the visit. At 9:12 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Entrance interview conducted.

Allegation: Staff do not prevent a resident from disturbing other residents.

It was alleged that staff did not prevent a resident from disturbing other residents. LPA requested facility documents relevant to the investigation which include but not limited to admissions agreement,
Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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 3
Control Number 31-AS-20240819162154
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: FORBES HOME
FACILITY NUMBER: 197610252
VISIT DATE: 08/27/2024
NARRATIVE
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physicians report, staff roster, resident roster, appraisals, and other related documents. LPA reviewed records between 11-11:20 AM. LPA interviewed six (6) staff and three (3) out of four (4) residents between 9:34 AM-11 AM.

During the interviews with designee and staff stated that resident #2 (R2) sometimes would play music on their tablet very loud during the times of 2-4 AM. During interviews with residents, R1 stated that R2 who resides adjacent to R1 bedroom plays their tablet very loud which could be heard in R1 bedroom. R2 and staff does not deny this allegation and stated that they do play their tablet in a loud volume around 2-4 AM.

Based on interviews and observations, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.



Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240819162154
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: FORBES HOME
FACILITY NUMBER: 197610252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
08/28/2024
Section Cited
CCR
80072(a)(3)
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Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping...
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This is an amended report to change the deficiency from Type A to Type B. The administrator/ licensee will review regulation and submit a written letter and meeting certifying that, moving forward, they will ensure to follow and adhere to
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 This requirement is not met as evidenced by: Based on interviews, R2 is disruptive during bedrime of 2-4AM when playing music on their tablet which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.
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CCR Title 22 Personal Rights of Residents. POC cleared today's visit.
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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: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
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