197610309-9-11-2024-31-AS-TAGD-DAKRWF-20241031132304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610309
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:12:44 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.ASC, 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
05/08/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240508090519

FACILITY NAME:	VALLEY STAR OLIVE VIEW UCLA CRT		FACILITY NUMBER:	197610309
ADMINISTRATOR:	VICTORIA MELNIKOVA		FACILITY TYPE:	772
ADDRESS:	14119 BUCHER AVE		TELEPHONE:	(818) 290-5307
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	16	CENSUS: 13	DATE:	09/11/2024
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Gbenga Sowunmi - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Licensee does not ensure equipment is maintained to meet the necessary needs of program activities for clients in care

Licensee does not ensure retention limitations are followed for clients who require higher level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPA initially met with Program Director Arlisa Nimete and informed her of the purpose of the visit. Administrator Gbenga Sowunmi arrived later.

LPA conducted physical plant tour at 9:29 AM, requested copies of facility documents relevant to the investigation at 10:00 AM and interviewed additional staff and residents between 10:15 AM to 12:30 PM. Regarding the allegation that the Licensee does not ensure equipment is maintained to meet the necessary needs of program activities for clients in care, it was alleged that Resident #1 (R1) had a behavioral episode and destroyed all the computers in the computer lab and broke the television in the facility and was not replaced immediately. LPA's observation during visit on 05/16/24 at 1:00 PM revealed that the computer was already fixed and properly working. LPA interview with the administrator on 05/16/24 at 1:30 PM revealed that the computers were replaced the same day and operational the next day, but the television was not yet replaced, and it had to be purchased and needed approval from the corporate office.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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-20240508090519

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY STAR OLIVE VIEW UCLA CRT	FACILITY NUMBER: 197610309
	VISIT DATE: 09/11/2024

NARRATIVE

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(continued from LIC 9099)

LPA's interview with the Quality Manager on 05/16/24 at around 2:00 PM, confirmed that the computers were replaced the same day it was broken. The television however was requested on the same day and still awaiting approval at the day of the initial visit on 05/16/24. LPA's observation during this visit revealed that the television has been replaced and properly working. There are always two (2) television set at the facility one is on the ground floor and the one which got broken on the second floor. The television set at the ground floor in the dining area was never broken and any or all of clients could use at any time at their leisure.

Regarding the allegation that Licensee does not ensure retention limitations are followed for clients who require higher level of care, it was alleged that R1 requires more care and supervision than is provided by the facility, LPA's interview with R1's clinician revealed that R1 is well within the parameters for care at this facility. Further interview also revealed that R1 was triggered by Resident #2 (R2) which caused the destructive behavior of R1. After R1 was hospitalized, R2 apologized to R1 and there was no more behavioral incident of R1 happened at the facility until R1's discharged on 08/05/24. LPA's record review today between 12:30 PM to 1:30 PM, confirmed that there was no more reported incident regarding R1.

Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

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