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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610497
Report Date: 05/01/2024
Date Signed: 05/01/2024 04:44:50 PM

Substantiated


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
04/29/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20240429113409
FACILITY NAME:AMEND TREATMENT - PORTSHEADFACILITY NUMBER:
197610497
ADMINISTRATOR:FLINN, DIANEFACILITY TYPE:
772
ADDRESS:6766 PORTSHEAD ROADTELEPHONE:
(805) 912-6363
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY:6CENSUS: 4DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Saro Altinoglu, Program Director TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Licensee did not ensure facility has clearance for non-ambulatory clients
Staff are not trained for non-ambulatory clients
Licensee did not ensure facility is wheelchair accessible for non-ambulatory clients
Staff do not ensure reporting requirements are followed
INVESTIGATION FINDINGS:
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13
At 10:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with the Program Director and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:30am, LPA requested resident and staff roster. At 10:35am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Staff Training, relevant to the investigation. At approximately 10:40am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:50am – 1:00pm, LPA conducted an interview with the Program Director, Clinical Program Director, one (1) staff and four (4) clients.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 7
Control Number 31-AS-20240429113409
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: AMEND TREATMENT - PORTSHEAD
FACILITY NUMBER: 197610497
VISIT DATE: 05/01/2024
NARRATIVE
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Allegation: Licensee did not ensure facility has clearance for non-ambulatory clients

It was alleged that the facility did not have a clearance for non-ambulatory clients, and one (1) out of four (4) clients was using a wheelchair. To investigate this allegation, LPA conducted an interview with four (4) out of four (4) clients and all clients confirmed that the facility has a client that uses a wheelchair (20-30%) of the time and mostly when taken for an outing. Moreover, all clients also informed the LPA that C1 uses the wheelchair, occasionally, inside the facility for couple of hours. LPA also conducted a review of C1’s Physician’s Report, and in an “Ambulatory status of a client” section it indicated that C1 is Non-ambulatory. Lastly, LPA reviewed a Fire Clearance granted on 03/22/24, and observed that the facility is approved for six (6) Ambulatory clients only. Based on information gathered during today’s visit this allegation is Substantiated.

Allegation: Staff are not trained for non-ambulatory clients

It was alleged that the staff are not trained for non-ambulatory clients. To investigate this allegation, LPA conducted an interview with the Program Director and a Clinical Program Director and was informed that prior to C1 moving to this facility an email was sent to all facility staff members regarding C1’s condition and what to expect when seizure episodes occur. However, no actual in-house training was conducted, and no staff training certificates were available. Based on interviews and record reviews this allegation is Substantiated.

Allegation: Licensee did not ensure facility is wheelchair accessible for non-ambulatory clients

It was alleged that the facility is not wheelchair accessible. To investigate this allegation, at 10:50am LPA conducted a physical tour of the facility and did not observe the facility installed a wheelchair accessible entrance and or had various portable ramps. Interview with the Program Director and a Clinical Program Director revealed that C1 was using a wheelchair at times. Moreover, interviews with all four (4) clients confirmed that, occasionally, C1 does use a wheelchair inside the facility. Interviews also revealed that on 04/24/24 the facility ordered a ramp and it was placed in C1’s room during today's visit. Lastly, LPA reviewed a Fire Clearance granted on 03/22/24, and observed that the facility is approved for six (6) Ambulatory clients only. Based on LPA’s observation and interviews gathered during today’s visit this allegation is Substantiated.


Continue on LIC9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 31-AS-20240429113409
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: AMEND TREATMENT - PORTSHEAD
FACILITY NUMBER: 197610497
VISIT DATE: 05/01/2024
NARRATIVE
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Allegation: Staff do not ensure reporting requirements are followed

It was alleged that the facility had two incidents that took place between 04/24/24 to 04/27/24 and the staff did not ensure reporting requirements were followed. During today’s visit, LPA conducted an interview with the Program Director and a Clinical Program Director and four (4) clients, and all parties interviewed confirmed that few incidents did occur around that time frame. However, LPA conducted a review of Licensing Information System (LIS) and did not observe incidents being submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Program Director and a Clinical Program Director that all staff members are mandated reporters, and they are all responsible for reporting. Based on interviews and record reviews this allegation is Substantiated.



Per the California Code of Regulations, deficiencies are cited and noted on LIC9099-D.

Exit interview conducted, appeal rights explained and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 31-AS-20240429113409
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: AMEND TREATMENT - PORTSHEAD
FACILITY NUMBER: 197610497
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2024
Section Cited
CCR
81020(b)(2)
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Fire Clearance: (b) The applicant shall notify the licensing agency if the facility plans to admit any of the following... (2) Persons who are non-ambulatory, as defined in Section 81001(n)(2).
This requirement is not met as evidenced by:
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Licensee must submit LIC200 along with the facility sketch by POC date.
Immediate civil penalty will be assessed.
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Based on interview and record review, the licensee did not comply with the section cited above by accepting a non-ambulatory (wheelchair) client (C1) without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons 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: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20240429113409
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: AMEND TREATMENT - PORTSHEAD
FACILITY NUMBER: 197610497
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2024
Section Cited
CCR
81061(b)
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7
Reporting Requirements: (b) Upon the occurrence… …a report shall be made to the licensing agency within the agency's next working day... In addition, a written report… …shall be submitted to the licensing agency within 7.
This requirement is not met as evidenced by:
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Licensee agreed to submit two incidents to LPA by POC date.
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Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the two (2) incidents that occurred between 04/24/24 -04/27/24, which poses/posed a potential health and safety risk to persons in care.
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Type B
05/08/2024
Section Cited
CCR
81066(b)
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Personnel Records: (b) Staff training as required by Section 81065(r) shall be documented. Documentation shall include the subject of the training, who conducted the training, and the date(s) of the training.
This requirement is not met as evidenced by:
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Administrator will conduct in-service training to all staff and submit proof of trainig by POC date
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Based on interviews and record reviews, the licensee did not comply with the section cited above by not providing a proper training to all staff on how to handle clients with seizures, which poses/posed a potential health and safety risk to persons 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: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
04/29/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20240429113409

FACILITY NAME:AMEND TREATMENT - PORTSHEADFACILITY NUMBER:
197610497
ADMINISTRATOR:FLINN, DIANEFACILITY TYPE:
772
ADDRESS:6766 PORTSHEAD ROADTELEPHONE:
(805) 912-6363
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY:6CENSUS: 4DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Saro Altinoglu, Program Director TIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical care for client in a timely manner
Staff did not ensure adequate care and supervision was provided to client
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 10:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with the Program Director and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:30am, LPA requested resident and staff roster. At 10:35am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Staff Training, relevant to the investigation. At approximately 10:40am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:50am – 1:00pm, LPA conducted an interview with the Program Director, Clinical Program Director, one (1) staff and 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: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 31-AS-20240429113409
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: AMEND TREATMENT - PORTSHEAD
FACILITY NUMBER: 197610497
VISIT DATE: 05/01/2024
NARRATIVE
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Allegation: Staff did not seek medical care for client in a timely manner

It was alleged that C1 had a seizure in the vehicle while going on another outing last week and the staff did not know how to handle the situation. To investigate this allegation, LPA conducted an interview with the Program Director and a Clinical Program Director and was informed that due to a type of seizure C1 did not require a medical attention. Interview with four (4) clients confirmed the above statement and all client expressed no concern regarding this allegation. Interview also confirmed that there was no immediate health and safety risk to the client, therefore 9-1-1 was not called. Based on interviews and record reviews this allegation is deemed Unsubstantiated at this time.

Allegation: Staff did not ensure adequate care and supervision was provided to client

It was alleged the client was discovered in a closet hitting themselves last week (date unknown). To investigate this allegation, LPA conducted an interview with the Program Director and a Clinical Program Director, one (1) staff and four (4) clients and was informed that due to C1’s mental condition, C1 has a tendency of hitting self. LPA was also informed that all staff are aware of C1’s behavior and provide an extra attention to be able to redirect and prevent C1 from hurting self. Moreover, four (4) clients interviewed expressed no concern regarding this allegation. Based on the information gathered during today’s visit, this allegation is deemed Unsubstantiated at this time.

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

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

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7