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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610503
Report Date: 03/06/2025
Date Signed: 03/06/2025 02:55:47 PM

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
02/19/2025 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20250219094156
FACILITY NAME:FAIRHAVEN HOME 2FACILITY NUMBER:
197610503
ADMINISTRATOR:CHENG, CHRISTINEFACILITY TYPE:
735
ADDRESS:21036 CHASE STREETTELEPHONE:
(818) 274-1809
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 5DATE:
03/06/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Joseph Jose, Licensee TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Licensee did not ensure adequate smoke detectors were in place in the facility.
Facility staff allow clients to smoke inside of the facility.
Facility staff are not providing transportation to clients.
Facility staff are not providing clients with mattresses that are in good condition.
INVESTIGATION FINDINGS:
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On 3/6/2025 at 9:30am, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan, Angela Panushkina and Huma Rahimi conducted a subsequent visit to the facility to deliver final findings. Upon arrival LPAs met with the House Manager/Caregiver Helen Delorfino, introduced themselves by showing badges and explained the reason for the visit.

LPAs requested resident and staff rosters at 9:45am, and 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.
During the initial visit made on 2/19/2025, LPA Khurshudyan conducted interviews, records review and obtained copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Incident Reports, Facility sketch, Facility Program Design and other documents relevant to the investigation.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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 5
Control Number 31-AS-20250219094156
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: FAIRHAVEN HOME 2
FACILITY NUMBER: 197610503
VISIT DATE: 03/06/2025
NARRATIVE
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LPA interviewed the House Manager /Caregiver, Administrator, two (2) out of four (4) clients. One (1) out of four (4) clients was at day program, and one (1) out of four (4) clients (C1) was having behavioral episode and LPA was unable to communicate and interview.

Allegation: Licensee did not ensure adequate smoke detectors were in place in the facility

It was reported that on 2/14/25, a credible witness from North Los Angeles Regional Center (NLARC) conducted an unannounced visit to the facility and observed that smoke detector was not located in C1's room. LPA conducted interview with Administrator, Caregiver, and two (2) out of four (4) clients, who confirmed and stated that C1 removed the smoke detector because C1 smokes inside his/her room and doesn’t follow the house rules. Based on observation and information obtained during the interviews, there is sufficient evidence to conclude that the above allegation is Substantiated.

Allegation: Facility staff allow clients to smoke inside of the facility.

It was reported that on 2/14/25, a credible witness from NLARC conducted an unannounced visit to the facility and two (2) clients claimed that C1 uses “hard drugs” in their bedroom. To investigate the allegation, LPA conducted interviews with the Administrator, House Manager/Caregiver, Licensee and two (2) out of four (4) clients in care who confirmed that they witnessed C1 use “hard drugs” and alcohol. LPA was also informed that the smoke detector in C1’s room was removed by C1, so that C1 could use the drug and or smoke. Based on information obtained, there is sufficient evidence to confirm that the above allegation is Substantiated.

Allegation: Facility staff are not providing transportation to clients.

It was reported that on 2/14/25, a credible witness from NLARC conducted an unannounced visit to the facility and gathered information that staff are not providing transportation to clients as contracted. LPA conducted interview with Administrator, who confirmed that there are times that staff need to reschedule clients’ weekly outings due to not having transportation available in the facility. Administrator informed LPA that she did escalate this issue to the Licensee, however, the status is still pending, and no major changes have been done. Based on information obtained during the interview, there is sufficient evidence to conclude that the above allegation is Substantiated.

Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250219094156
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: FAIRHAVEN HOME 2
FACILITY NUMBER: 197610503
VISIT DATE: 03/06/2025
NARRATIVE
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Allegation: Facility staff are not providing clients with mattresses that are in good condition.

It was reported that on 2/14/25, a credible witness from NLARC conducted an unannounced visit to the facility and observed that C2’s mattress is concave and not in good condition. During the initial visit, LPA conducted a physical tour and observed that all clients mattresses are new and in good condition. LPAs conducted an interview with the Licensee who confirmed that C2's mattress had to be replaced and on 02/13/25 the facility purchased and replaced C2's mattress. During today's visit LPAs visited five (5) out of five (5) clients' rooms and observed all clients mattresses are in good condition. Based on LPAs observation and interviews, this allegation is Substantiated.


Exit interview conducted, Deficiency issued on LIC9099-D

Copy of appeal rights and report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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:
FACILITY NUMBER:
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2025
Section Cited
CCR
80020(a)
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Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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During today's visit, LPAs observed C1's room smoke detector replaced. LPAs tested the smoke alarm and carbon monoxide and observed it to be operational.
POC is cleared during todays visit
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Based on credible witness’s observation made 02/14/25, the licensee did not comply with the section cited above by allowing C1 to remove the smoke detector in his/her room, which posed an immediate health and safety risk to clients in care.
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Type A
03/07/2025
Section Cited
CCR
80072(a)(1&3)
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Personal Rights:(a) each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons.
(3)To be free from corporal or unusual punishment...
This requirement is not met as evidenced by:
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Administrator is currently working with CCL and RC to relocate the client. New location will be submitted to LPA upon C1's departure.
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Based on a credible witnesses’ observation and LPAs interviews, licensee did not comply with the section cited above by not preventing C1 from smoking inside the facility, using alcohol and or “hard drugs”. This poses/posed an immediate health and safety risk to clients 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: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250219094156
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: FAIRHAVEN HOME 2
FACILITY NUMBER: 197610503
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2025
Section Cited
CCR
85088(c)(1)
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Fixtures, Furniture, Equipment and Supplies: (c) The licensee shall ensure provision to each client of the following furniture... (1) An individual bed..., maintained in good repair, and equipped with good bed springs, a clean mattress...
This requirement is not met as evidence by
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Administrator will purchase new mattresses for two out of four clients. Copy of the receipt will be submitted to LPA by POC due date.
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Based on LPAs observation, the licensee did not comply wth the section cited above by not assuring that all clients have mattresses in good repair. This poses a potential health and safety risks to clients in care.
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Type B
03/13/2025
Section Cited
CCR
80022(k)
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Plan of Operation …The plan of operation shall include the following information for the use of secured perimeters: (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.
This requirement is not met as evidenced by:
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LIcensee/Administrator agrees to submit a statement explaini g how they are going to provide the transportation or make an arrangements for transportation to transport the clients for medical appointments or other outings. The documents must be submitted to LPA by POC due date.
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Based on interviews and record reviews the licensee did not comply with the section cited above by failing to follow facility’s own Plan of Operation. Clients were not provided with transportation, which posed a potential health and safety risk to clients 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: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5