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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610252
Report Date: 10/04/2024
Date Signed: 10/06/2024 11:13:37 AM

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
09/27/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240927170054
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:
04:00 PM
ALLEGATION(S):
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Staff are storing expired food in the refrigerator.
Staff did not store an adequate amount of food for a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a initial 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 storing expired food in the refrigerator.

It’s being alleged the facility food is expired and the clients were sick as a result. LPA attempted to interview C2-C4, but was unable due to being out of the facility for a party.

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 2
Control Number 31-AS-20240927170054
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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During interview at 2PM S1-S3 unanimously stated the facility food is not expired and no clients have not become sick or complaint due to expired food. During the interview from staff and C1 it was revealed that expired food was not bought buy the staff and staff was advised not to touch R1 belonging in the refrigerator. S1 stated they check the food to ensure the food is not expired. During LPA 10.4.2024 visit, LPA did not observe expired food within the facility.

The allegation is deemed unsubstantiated at this time.

Allegation #2: Staff did not store an adequate amount of food for a resident in care.

It was alleged that R1 would not have their chicken broth, blueberry yogurt, vanilla pudding, fresh fruits, and apple sauce. To investigate the allegation, on 10.4.2024, LPA conducted a physical plant tour at around 12:23PM. LPA interviewed C1 and Administrator and staff from 12:47 PM to 1:16 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, fresh fruits, 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. Administrator and staff confirmed that there is enough food for all the clients and if they want extra, it can be provided to them. During LPA tour, LPA confirmed that there is enough food for four (4) clients. In addition, there is an extra refrigerator in the garage with extra food and pantries of food. Based on LPA observations, staff, and client interviews the above allegation is found to be 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: 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)
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