197610503-7-2-2026-31-AS-NMAN-DVZ6MX-20260714205639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610503
Report Date: 07/02/2026
Date Signed: 07/02/2026 03:18:36 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
04/20/2026 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20260420105031

FACILITY NAME:	FAIRHAVEN HOME 2		FACILITY NUMBER:	197610503
ADMINISTRATOR:	OSISANYA, ADEBAYO IGE		FACILITY TYPE:	735
ADDRESS:	21036 CHASE STREET		TELEPHONE:	(818) 274-1809
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 2	DATE:	07/02/2026
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Joseph Jose, Licensee		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

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Staff did not ensure resident had shoes that were in good condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with staff and the licensee was contacted. LPA spoke with the licensee over the phone, disclosed the purpose of the visit, and the licensee revealed will be enroute to the facility.

Regarding the allegation Staff did not ensure resident had shoes that were in good condition:

On 04/29/26, LPA Smith conducted a physical plant tour from 2:40 pm-3:00 pm. LPA Smith spoke briefly to two (2) staff. LPA Smith sent request to administrator for copy of personnel report and resident roster. All staff interviewed revealed that resident #1 (R1) shoes were in good condition and R1 did not ask them for assistance in obtaining any shoes. Staff also revealed that after R1 was admitted as emergency placement on 01/22/26, staff and R1 returned the following day to R1’s parent home to pick up R1’s remaining items to include a large box or tub of shoes.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026

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-20260420105031

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: FAIRHAVEN HOME 2	FACILITY NUMBER: 197610503
	VISIT DATE: 07/02/2026

NARRATIVE

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(Cont from 9099)

Interview with two (2) of (2) residents revealed they do not recall R1 having torn shoes but insist that staff are helpful and would provide them with shoes or clothing if they needed it. Review of personal property and clothing records for current residents shows documentation accounting for at least one pair of shoes. During the facility tour, LPA Smith observed both residents’ rooms/garage and confirmed that each resident had at least two (2) or more pairs of shoes in good condition available.

Based on information obtained through interviews, record review, and observation, this allegation is deemed Unsubstantiated at this time.

No hazards observed at time of visit.

Exit interview conducted/copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026

LIC9099 (FAS) - (06/04)

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