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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610399
Report Date: 09/25/2025
Date Signed: 11/21/2025 12:16:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/16/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20250916095745
FACILITY NAME:EMPOWER RESIDENTIAL WELLNESS CENTER LLCFACILITY NUMBER:
197610399
ADMINISTRATOR:DAHLMANN, MARIAFACILITY TYPE:
772
ADDRESS:22119 BASSETT STREETTELEPHONE:
(818) 209-5011
CITY:CONOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY:6CENSUS: 4DATE:
09/25/2025
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Shawn Mokricky, Operations ManagerTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff do not provide a good quality of food to residents in care.
Facility does not have an adequate supply of food.
Staff did not provide resident with linens.
Staff did not ensure the facility was free of vermin feces.
Staff violated residents rights

INVESTIGATION FINDINGS:
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This is an amended to the original report issued 09/25/2025. Additional information was added to clarify the investigation.

At 8:55am, Licensing Program Analyst (LPA), Angela Panushkina conducted an unannounced visit in response to the above-mentioned allegations. LPA met with the Operations Manager and Program Director and explained the reason for the visit.

At 9:00am, LPA requested client and staff roster. At 9:05am requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s report, Appraisal Needs and Services Plan, Individual Therapy Notes, Menu, relevant to the investigation. At approximately 9:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 9:20am – 11:00am, LPA conducted interviews with the Program Director, Operations Manager, Behavior Technician, Licensed Vocational Nurse (LVN) and four (4) out of four (4) clients. Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025
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 3
Control Number 31-AS-20250916095745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 197610399
VISIT DATE: 09/25/2025
NARRATIVE
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Allegation: Staff do not provide a good quality of food to residents in care.

It was alleged that the facility doesn’t provide quality food to residents. To investigate this allegation LPA conducted interviews with staff and clients. All staff interviewed informed LPA that food is served fresh and that they are not aware of any complaints as it pertains to food. LPA was also informed that the facility purchases groceries every Saturday or as needed. Upon a new client’s admission, once the staff is aware of special diets, allergies or other restrictions/limitations, an additional grocery shopping is being scheduled immediately. Four (4) clients interviewed expressed no concern regarding this allegation and informed LPA that they are satisfied with the quality of food. All clients stated that the facility has plenty of food and the staff will always purchase extra, upon request. Lastly, LPA visited the kitchen and inspected the kitchen cabinets and two (2) refrigerators. LPA observed two-day perishable and seven-day non-perishable food supply. LPA also observed a daily/weekly/monthly menu available. Therefore, based on interviews, LPA inspection and observation, this allegation is deemed Unsubstantiated, at this time.

Allegation: Facility does not have an adequate supply of food.

At approximately 9:15am, LPA conducted a physical plant tour to the kitchen and observed two (2) fully stocked refrigerators. Top shelf had leftovers with labeled containers. Middle shelf is used for dairy, eggs, etc. One drawer was designated for fruits and the other for vegetables. The freezer area had plenty of meat such as: chicken, fish, ground beef, etc. LPA was informed that the facility purchases food supply from Amazon and Walmart. During today’s visit four (4) clients interviewed did not express any concern regarding the above allegation. Therefore, based on LPA observation, inspection and interviews this allegation is deemed Unsubstantiated, at this time.

Allegation: Staff did not provide resident with linens.

It was alleged that the facility bedding/linen was old and had an odor to them. To investigate this allegation, LPA conducted an interview with the Operations Manager and was informed that currently, the facility has twelve (12) sets of open linen and seven (7) brand new sets that are still in the boxes. Four (4) clients interviewed expressed no concern regarding this allegation and informed LPA that the bedding/linens are being changed at least once a week or as needed and no smell has been observed. LPA visited all six (6) bedrooms, designated for clients use and observed all beds, bed sheets, comforters, pillows and pillowcases are in good condition and no odor was present. Therefore, based on LPA observation, inspection and interviews this allegation is deemed Unsubstantiated, at this time. Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250916095745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 197610399
VISIT DATE: 09/25/2025
NARRATIVE
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Allegation: Staff did not ensure the facility was free of vermin feces.

It was alleged that in the dresser drawers, in C1’s room, C1 observed rat droppings. To investigate this allegation, LPA conducted an interview with the Regional Clinical Director and Operations Manager and was informed that the facility had never had any issues with rat/vermin and they’ve never seen and or herd of any droppings. All clients interviewed also denied the above allegation and informed LPA that upon their admission the rooms were very clean and presentable, and no issues were observed. During the facility's physical plant tour LPA checked all six (6) dresses and did not observe vermin feces and or smell. Therefore, based on LPA observation, inspection and interviews this allegation is deemed Unsubstantiated, at this time.

Allegation: Staff violated residents rights

To investigate this allegation, LPA conducted an interview with the Regional Clinical Director (RCD), who stated the following: “Once the client arrives, we ask them to sign all paperwork (Admission Agreement, Identification, Consent, Personal Belongings Inventory…). The clients are being notified that we do the inventory to make sure that they don’t have anything hidden that can harm them or others.” LPA was also informed that prior to C1’s admission to the facility, C1 had a fall incident at Los Angeles International (LAX) airport. Thus, C1 arrived at the facility very late at night and C1 was thinking of going to Emergency Room (ER). C1 agreed to allow the staff to register their personal belongings while C1 signed agreements and rest of the facility documents with RCD. However, C1’s behavior changed and C1 accused the staff of stealing their identity. The staff immediately stopped C1’s personal item inventory as soon as they received C1’s verbal refusal. LPA was also informed that an Incident Report regarding this issue was submitted to the Community Care Licensing Division (CCLD). LPA observed that the incident was submitted to CCLD within the timely manner. Interview with the Operations Manager and Behavior Technician confirmed the statement provided by the RCD. Four (4) residents interviewed expressed no concerns regarding this allegation. Lastly, LPA conducted review of the facility Admission Agreement and observed that C1 initialed and consented to the section under Basic Services: item (o), authorizing maintenance or supervision of client/resident property, if necessary. Therefore, based on LPA observation, inspection and interviews this allegation is deemed Unsubstantiated, at this time.

No deficiency issued during today's visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3