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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610252
Report Date: 08/27/2024
Date Signed: 08/27/2024 12:45:57 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
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 provide a safe environment for residents in care.
INVESTIGATION FINDINGS:
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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 provide a safe environment for residents in care. LPA requested facility documents relevant to the investigation which include but not limited to admissions agreement,

Continue to LIC 9099-C
Unsubstantiated
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 2
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 two (2) residents between 9:34 AM-11 AM.

Interview revealed that R2 is non-ambulatory and wheelchair bound, two (2) out of two (2) of residents have not witness or encounter an issue with R2. Further interview also revealed that R2 depends on staff every minute, staff did not witness such occurrence.

Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report 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 2