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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610252
Report Date: 10/04/2024
Date Signed: 10/04/2024 01:54:22 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
08/09/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240809172603
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:
10/04/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lucky Pana- AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not adequately trained to manage resident’s behaviors.
Staff spoke to resident in an inappropriate manner.
Staff did not provide resident with adequate food service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Lucky Pana, and advised them about the visit. At 12:22 PM LPA conducted a physical plant tour to ensure the health and safety of the clients in care.

An entrance interview was conducted.

Allegation #1: Staff are not adequately trained to manage resident’s behaviors.

Regarding the above allegation, it is alleged that the facility staff are not adequately trained to manage clients' behaviors. Staff would gang up and verbally attack R1. LPA conducted a physical plant tour on 12:23 PM at 12:38 PM.
Continue to LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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-20240809172603
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: 10/04/2024
NARRATIVE
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On 8.13.2024, LPA requested copies of facility documents relevant to the investigation at 3:30 PM. LPA reviewed facility documents from 2:17 PM to 3:30 PM and interviewed staff and clients between 11:19 AM to 1:14 PM. LPA interview with five (5) staff on 8.13.2024 between 1:30 PM to 2:16 PM. Interviews and records reviews revealed that staff had undergone training before working and had at least eighty (80) hours of on-the-job training/shadowing at the facility.

Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation #2: Staff spoke to resident in an inappropriate manner.

Regarding the above allegation, it is alleged that the facility staff inappropriately spoke to R1. LPA interviewed three (3) out of four (4) clients from 11:19 to 1:14 PM and five (5) staff on 8.13.2024 between 1:30 PM to 2:16 PM. Interviews from clients revealed that they are happy and have not experience such treatment from staff. Interviews with staff revealed that they treat all their clients with respect and dignity.

Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation #3: Staff did not provide resident with adequate food service.

Regarding the allegation that the staff does not provide adequate food service. It was alleged that R1 would not have their chicken broth, blueberry yogurt, vanilla pudding and apple sauce. To investigate the allegation, on 8.13.2024 and 10.4.2024, LPA conducted a physical plant tour at around 12:23PM. LPA interviewed three (3) out of four (4) clients from 11:19 to 1:14 PM and five (5) staff on 8.13.2024 between 1:30 PM to 2:16 PM. LPA requested copies of facility documents relevant to the investigation at 3:30 PM. During the physical plant tour, LPA observed abundant supplies of Swanson’s and Kirkland chicken stock new and sealed in the pantry and refrigerator. Different flavors of Yoplait yogurt, apple sauce and Snack-Pack pudding were available that are properly stored and new in the refrigerator as well. LPA check for the expiration date on the food in the pantry and refrigerator and everything is valid. A review of the
Continue to LIC 9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240809172603
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: 10/04/2024
NARRATIVE
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facility’s menu shows facility serves well-balanced meals with a variety of choices. Exit interview conducted and copy of this report is given.

Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3