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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610252
Report Date: 01/22/2025
Date Signed: 05/02/2025 08:10:13 AM

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
01/16/2025 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20250116094029
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:
01/22/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lucky Pana- administratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not ensure resident's door was not in disrepair.
Staff are not providing a comfortable environment for resident.
INVESTIGATION FINDINGS:
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This is an amendment of the original report issued 01-22-2025. The report is being amended to clarify the details of the findings.

Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Angela Panushkina conducted an initial complaint visit to the facility to investigate the above allegations. LPAs met with the administrator, Lucky Pana, and the assistant administrator Lora May Pana, and advised them about the visit. At 9:42 AM, LPAs conducted a physical plant tour to ensure the health and safety of the clients in care.

An entrance interview was conducted.

Allegation #1: Staff did not ensure the resident's door was not in disrepair.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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 6
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
01/16/2025 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20250116094029

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:
01/22/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lucky Pana- administratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff made inappropiate comments towards resident.
Staff did not ensure resident's passageway was free of obstruction.
Staff are not providing adequate food service to resident.
Staff did not ensure the shower chair was clean.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Angela Panushkina conducted a initial complaint visit to the facility to investigate the above allegations. LPAs met with the administrator, Lora May Pana and Lucky Pana, and advised them about the visit. At 9:42AM LPAs conducted a physical plant tour to ensure the health and safety of the clients in care.

An entrance interview was conducted.

Allegation #1: Staff made inappropriate comments towards resident.

Regarding the above allegation, it is alleged that the licensee made inappropriate comments towards client #1 (C1). LPAs interview with four (4) staff on 1.22.2025 between 10:32 AM to 11AM.

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

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20250116094029
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: 01/22/2025
NARRATIVE
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At 10:32 AM LPA called licensee to interview the allegation stating, “If you don’t like it, you can leave.”. LPA interview staff at 10:40AM and unanimously stated that licensee did not and would never state such comments to clients. LPA interviewed three (3) out of four (4) clients from 10:30-11AM. 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 interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation #2: Staff did not ensure resident's passageway was free of obstruction.

It was alleged that facility staff did not ensure C1 bedroom #3 passageway was free of obstruction. At 9:42 AM LPAs was able to tour the facility in order to investigate this allegation. While touring C1's room, LPAs did not observed any blockage within the surrounding areas or on any of the residents bedrooms and emergency exit pathway.

Based on the observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation #3: Staff are not providing adequate food service to resident.

It was being alleged that the facility served milk that is expired and the clients were sick as a result. During interview at staff interview, staff unanimously stated the facility milk is not expired and no other clients have not become sick or complaint due to expired food. Facility does the groceries once a week to ensure the freshness of food. LPAs interview three (3) out of four (4) clients and unanimously agreed that no expired milk/ food is ever given to the them. During the visit, LPAs did not observe expired food within the facility. LPAs check for the expiration date on the food in the pantry and refrigerator and everything is valid.

Based on the observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
Continue to LIC 9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20250116094029
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: 01/22/2025
NARRATIVE
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Allegation #4: Staff did not ensure the shower chair was clean.

It was alleged that the clients shower chair is un-clean and has feces. During LPAs physical plant tour at 9:42AM it was revealed that the facility has two (2) bathrooms that C1 has access. During the tour LPAs observed both bathrooms to be very clean with no discoloration, tear, or feces in sight. Interview with staff at 11AM 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: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20250116094029
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: 01/22/2025
NARRATIVE
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It was alleged that the facility staff did not ensure the resident’s back emergency door was not in disrepair. Client #1 (C1) resides in bedroom #3, and their emergency back door keeps popping open when vibration occurs. This emergency door in bedroom #3 leads to the emergency exit outside the facility. This issue was reported to the staff and the licensee. The licensee stated that ‘this is an alignment issue’ leaving the emergency door not being repaired. During LPAs' visit on 1.22.2025 at 9:42 AM LPAs did not observe the emergency door popping open and no vibration was observed or felt. However, LPAs observed that the back emergency door needed to be at an angle to properly close and latch shut.

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

Allegation #2: Staff are not providing a comfortable environment for resident.

It is alleged that the facility does not provide an adequate comfortable environment for the resident. In bedroom #3, C1’s back emergency exit door (that leads to the outside of the facility) has a gap to the bottom left of around 0.12 inches that causes a cold draft or dust to come into bedroom #3. During today’s visit 1.22.2025 at 9:54 AM LPAs observed in bedroom #3 emergency door has a cold air draft that enters the bedroom even when the emergency door is locked and shut. This causes C1 to be uncomfortable to have outside dusty air to come in and cold air flowing in bedroom #3.

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

Deficiencies and appeal rights given.

Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20250116094029
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: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
80087(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Licensee/Administrator will need to fix/replace/repair the exit door and a window in C1’s room. Copy of the receipt or pictures will be submitted to LPA by POC date.
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Based on LPAs observation during the physical plant tour, licensee did not comply with the section cited above by not ensuring that C1’s exit door and the window are in good repair. This poses a potential health and safety risk to the clients in care.
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Type B
01/29/2025
Section Cited
CCR
80072(a)(2)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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Licensee/Administrator agreed to submit a comprehensive plan on how the facility will ensure each resident is accorded a safe, healthful and comfortable environment by POC date.
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Based on interviews and observation, licensee failed to ensure that residents are accorded a safe, healthful and comfortable accommodations due to C1 continuing to smoke inside the bedroom with oxygen tank, which causes an immediate health and safety risk to residents in care.
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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: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6