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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610252
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:17:27 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
10/22/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20241022161343
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:
10/28/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lucky Pana-AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff serve expired milk to the resident
Staff deny resident food
Staff "bully" resident
Staff gave resident a used "wipe" to clean resident
Staff do not ensure shower chair is cleaned properly
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 9:15 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 serve expired milk to the resident

It was being alleged that the facility served milk that is expired and the clients were sick as a result. During interview at 2PM S1-S7 unanimously stated the facility milk is not expired and no other clients have not become sick or complaint due to expired food.

Continue to LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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-20241022161343
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: 10/28/2024
NARRATIVE
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Facility does the groceries once a week to ensure the freshness of food. LPA interview C2-C4 and unanimously agreed that no expired milk/ food is ever given to the them. During the visit, LPA did not observe expired food within the facility. LPA check for the expiration date on the food in the pantry and refrigerator and everything is valid.

The allegation is deemed unsubstantiated at this time.

Allegation #2: Staff deny resident food

It was alleged that staff would deny clients food (lunch). To investigate the allegation, LPA conducted a physical plant tour at around at 9:15 AM. During LPA interviewed C1 and Administrator and staff from 12 NN to 1:30 PM. During the physical plant tour, LPA observed abundant supplies of Swanson’s, Kirkland chicken stock new and sealed different flavors of Yoplait yogurt, fresh fruits, apple sauce, Snack-Pack pudding, fresh fruits, vegetables, cheese and meat. Administrator and staff confirmed that breakfast, lunch, and dinner is served in a timely manner everyday by staff. LPA observed there is enough food for all the clients and if they want extra, it can be provided to them. LPA interview C2-C4 and unanimously agreed that breakfast, lunch, snacks, and dinner are always served on time. During LPA interview it was also revealed that clients are never denied food. Based on LPA observations, staff and client interviews the above allegation is found to be UNSUBSTANTIATED at this time.

Allegation #3: Staff "bully" resident

It was alleged that the staff 'bully' the clients which causes C1 mental stress. LPA requested copies of facility documents relevant to the investigation at 1:30 PM. LPA reviewed facility documents from 11 AM to 2:30 PM and interviewed staff and clients between 12 NN to 12:30 PM. LPA interview with administrator and six (6) staff between 12:30 PM to 1:30 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.
LPA interviewed three (3) out of four (4) clients from 12NN to 12:30 PM, administrator and six (6) staff between 12:30 PM to 2:30 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.
Continue to LIC 9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241022161343
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: 10/28/2024
NARRATIVE
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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 #4: Staff gave resident a used "wipe" to clean resident.

It was alleged that a staff gave C1 some wipes with feces on the flap of the wipes. During LPA physical plant tour LPA observed all of the wipes in the clients bedroom and both bathrooms were clean. LPA also observed all interior surfaces to be sanitary. LPA interview C2-C4 and unanimously agreed that the wipes that are used in the facility are always clean without contamination. LPA interview staff and stated that the wipes were taken from the cabinet in the living room, which is a new package during the allegation. Based on observation and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation #5: Staff do not ensure shower chair is cleaned properly.

It was alleged that the clients shower chair is un-clean and has feces. During LPA physical plant tour it was revealed that the facility has two (2) bathrooms. During the tour LPA observed both bathrooms to be very clean with no discoloration or feces in sight. Interview with staff at 12:30 PM revealed that when C1 always uses bathroom #1 that is located in between the kitchen and the dining room. C1 rarely uses the bathroom #2; which is only for showers, that has a shower chair that is located in between bedroom #1 and bedroom #2.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is 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: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3