197610258-4-5-2024-31-AS-EMIR-D4DPU4-20240416113656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610258
Report Date: 08/29/2023
Date Signed: 04/05/2024 12:06:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
08/22/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230822174145

FACILITY NAME:	HOME FOR THE ELDERLY		FACILITY NUMBER:	197610258
ADMINISTRATOR:	GACAYAN, CAMERON		FACILITY TYPE:	740
ADDRESS:	19825 LEADWELL ST.		TELEPHONE:	(818) 718-2750
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 5	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Enlinda Sajor- Administrator Designee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility has staff or other person living in garage not permitted for occupancy

INVESTIGATION FINDINGS:

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This is an amended report of the prior investigation report delivered on 08/29/23. Licensing Program Analysts (LPAs) Mariana Agban and Raymond Comer conducted a subsequent complaint visit to this facility. LPAs met with Administrator Designee Enlinda Sajor and explained the reason for the visit. LPAs conducted a physical plant tour, to ensure the health and safety of the clients are protected and physical plant is in compliance with Title 22 Regulations.

Based on further review, the findings of this complaint will change from Unfounded to Unsubstantiated.

Exit Interview conducted a copy of this report delivered.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230822174145

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOME FOR THE ELDERLY	FACILITY NUMBER: 197610258
	VISIT DATE: 08/29/2023

NARRATIVE

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Staff room has 3 beds where the 3 staff members sleep in. Interview with House Manager revealed that couple weeks ago S2 called 911 for S1 to be taken to the hospital. House Manager stated that shortly after S1 passed away. In addition, House Manager provided staff roster and facility sketch to confirm that all staff are residing in the employee room.

Based on interviews and observations, the allegation has been found to be unfounded at this time.

Exit interview conducted and a copy of the report was signed and delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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