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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610504
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:08:41 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
02/14/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250214122033
FACILITY NAME:FAIRHAVEN HOME 4FACILITY NUMBER:
197610504
ADMINISTRATOR:CHENG, CHRISTINEFACILITY TYPE:
735
ADDRESS:19730 KITTRIDGE STREETTELEPHONE:
(818) 274-1809
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 5DATE:
03/06/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rebecca Obadan, StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is over ratio
Staff do not have required health clearance
Staff did not ensure resident had a table lamp and chair in room
Facility staff are using a common towel.
Common areas are being used for sleeping
INVESTIGATION FINDINGS:
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At 09:30 AM, Licensing Program Analysts (LPAs) Huma Rahimi, Angela Panushkina, and Perchui Milena Khurshudyan conducted an unannounced subsequent complaint visit. LPAs met with the staff Rebecca Obadan, and the Licensee Joseph Jose was contacted by phone. LPAs disclosed the reason for the visit.

An initial visit was conducted on 02/24/2025. At 1:05 PM, LPA requested clients and staff roster. At 1:10 PM, LPA requested copies of pertinent information which include, but not limited to Physician Report, Appraisal Needs and Services Plan, Staff Records and etc., relevant to the investigation. At approximately 1:15 PM, LPA conducted a physical plant tour. Between 1:20 PM – 03:30 PM, LPA conducted an interview with the Licensee, Administrator, Staff #1 (S1) and four (4) out of five (5) clients who were available at the facility.

Continue on LIC 9099
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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 6
Control Number 31-AS-20250214122033
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 4
FACILITY NUMBER: 197610504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2025
Section Cited
CCR
80065(g)(1)
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Personnel Requirements (g) All personnel, including the licensee, administrator and volunteers, shall be in good health,.....(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis,.....
This requirement is not met as evidenced by:

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Licensee obtained health screening for S1 and S2. POC cleared during today's vist.
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Baed on interviews and record reviews licensee did not comply with the section cited above by not having S1 and S2 TB cleared prior to employment with the facility which poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/07/2025
Section Cited
CCR
85088(c)(2)(4)
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(c) The licensee shall ensure provision to each client of the following furniture, equipment ....personal hygiene. (2) Bedroom furniture including, ....Bedroom furniture including, in addition to (c)(1) above, for each client, a chair,....(4) Clean linen in good repair,...... towels, hand towels and washcloths.

This requirement is not met as evidenced by:
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The Licensee placed a chair in C1's room and paper towel on 02/13/2025. POC cleared during the visit.
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Based on credible witness observation on 02/13/2025 and interviews C1 did not have a chair in his/her room and no paper towel in the clients bathroom which poses/posed a potential 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: Huma Rahimi
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: 2 of 6
Control Number 31-AS-20250214122033
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 4
FACILITY NUMBER: 197610504
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
85087(a)(3)
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(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements:(3) No room commonly used for other purposes shall be used as a bedroom for any person.
This requirement is not met as evidenced by:
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As of 02/15/2025 S1's employment was terminated. Licensee will conduct an in service training regarding this section with current and futher staff and copy of in service training will be submitted to LPA by POC date.
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Based on information obtained through interviews S1 did sleep in the common areas/living room. This poses a potential 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: Huma Rahimi
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: 3 of 6
Control Number 31-AS-20250214122033
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 4
FACILITY NUMBER: 197610504
VISIT DATE: 03/06/2025
NARRATIVE
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Facility is over ratio

The complainant concern is that the Licensee is operating outside of his approved ratio of clients. To investigate this allegation LPA reviewed the facility’s plan of operation, and per Licensee’s plan of operation, the Licensee will not lodge more than four (4) clients. According to the facility’s plan of operation the facility is operating outside of its ratio. Furthermore, LPA conducted an interview with the Licensee who confirmed that the facility already had four (4) clients when the Licensee accepted C1. Based on plan of operation review and interviews this allegation is Substantiated.

Staff do not have required health clearance

It was reported that during a random visit conducted on 02/13/2025, by the credible witness from NLARC that the facility staff did not have health clearance/TB on file. To investigate this allegation, LPA conducted an interview with the Licensee and the Administrator and both confirmed that S1 and S2 did not have a TB test clearance on file. Additionally, LPA conducted review of S1's and S2’s facility records and observed that S1 got hired on 12/06/2024 and S2 on 01/25/2025 and were not TB tested and cleared until 02/13/2025. Therefore, based on documentation review and interview this allegation is Substantiated.

Staff did not ensure resident had a table lamp and chair in room:

It was reported that during a random visit conducted on 02/13/2025, by the credible witness from NLARC that C1’s room did not have a table lamp and a chair in their bedroom. To investigate this allegation LPA conducted an interview with the Licensee who confirmed that C1’s bedroom did not have a chair on 02/13/2025; however, they placed a chair in C1’s room on that same day. Interview with C1 also confirmed the information provided by the Licensee. Based on the information gathered through interviews, this allegation is Substantiated.

Continue on LIC 9099C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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: 6 of 6
Control Number 31-AS-20250214122033
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 4
FACILITY NUMBER: 197610504
VISIT DATE: 03/06/2025
NARRATIVE
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Facility staff are using a common towel:

It was reported that during a random visit conducted on 02/13/2025, by the credible witness from NLARC that no paper towels were available in the restroom to ensure proper sanitation. To investigate this allegation LPA conducted interview with the Licensee and Administrator and both informed LPA that on 02/13/2024, the staff removed paper towels due to plumbing issue in one of the clients' bathroom. Furthermore, LPA conducted an interview with S2 who also confirmed the information provided by Licensee and Administrator. During the physical plant tour LPA observed paper towels in the bathroom and available for client’s use. Based on the information gathered through interviews there is enough evidence to support this allegation; therefore, the allegation is Substantiated.

Common areas are being used for sleeping:

It was reported that during a random visit conducted on 02/13/2025, by the credible witness from NLARC that S1 used common area’s couch to sleep. To investigate this allegation LPA conducted an interview with the Licensee and Administrator and both denied the allegation. Additionally, LPA conducted interview with four (4) out of five (5) clients and all confirmed that S1 did sleep in facility's common areas. Furthermore, LPA conducted a telephonic interview with S1 and who also confirmed that during their scheduled hours S1 slept in common areas. Based on the interviews this allegation is Substantiated.

Deficiencies cited on LIC 9099D. Appeal rights explained.

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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: 5 of 6
Control Number 31-AS-20250214122033
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 4
FACILITY NUMBER: 197610504
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
80022(k)
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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 has agreed to move/relocate C1. 30-day eviction notice was already submitted and issued. Upon C1's departure the Licensee will provide new location address and phone number of C1.
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Based on interviews. LPA's observation, and record review the Licensee did not comply with the sectioned cited above by admitting an additional client and not following the facility's own Plan of Operation and made the facility go over their ratio. This posed an immediate health and safety risks 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: Huma Rahimi
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 6