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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610504
Report Date: 03/12/2025
Date Signed: 03/12/2025 02:28:51 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
03/06/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20250306162853
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:
03/12/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christine Cheng, Administrator TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff retained a resident that required a higher level of care
INVESTIGATION FINDINGS:
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At 10:00am, Licensing Program Analyst (LPA), Angela Panushkina, arrived at Fairheaven Home 4 in response to the above-mentioned allegation. LPA met with the Administrator and explained the reason for the visit.

At 10:05am, LPA requested client and staff roster. At 10:10am requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Individual Program Plan (IPP), Approved Transportation schedule relevant to the investigation. At approximately 10:15pm, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:20pm – 12:30pm, LPA conducted an interview with the Licensee, Administrator, two (2) staff and five (5) out of five (5) clients.

Continue on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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-20250306162853
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 4
FACILITY NUMBER: 197610504
VISIT DATE: 03/12/2025
NARRATIVE
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Allegation: Staff retained a resident that required a higher level of care

It was alleged that the facility accepted a placement of C1 into a Level 2 vendored home and provided a service that was not approved for vendorization by North Los Angeles Regional Center (NLARC). Interview with the Licensee revealed that four (4) out of five (5) clients are currently Level 2 and only C1 requires to be in Level 4 home. Licensee found out about C1's level of care after C1 was admitted to this facility. An email sent to NLARC requesting a new placement for C1 (Level 4 home) in January 9th 2025. Licensee also informed LPA that the facility is currently working with NLARC and is in a process to relocate C1 to a proper (Level 4) home. Furthermore, LPA conducted review of four (4) out of five (5) client facility files and observed that C2’s, C3’s C4’s and C5’s Admission Agreement indicated Level 2 care to be provided by the facility. In addition, LPA conducted review of C1’s IPP and observed that C1’s came from Level 4 home. Lastly, LPA conducted a file review of the facility’s file to verify whether or not the facility had an approval to operate Level 4 home. LPA confirmed the facility do not have Level 4 Program approved by NLARC. Therefore, based on interviews and record reviews, this allegation is Substantiated.

Deficiency issued during today's visit 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: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250306162853
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 4
FACILITY NUMBER: 197610504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
85068.4(a)(3)
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Acceptance and Retention Limitations: (a) The licensee shall not accept or retain the following: (3) Persons who have needs that are in conflict with the needs of other clients or the program of services offered.
This requirement is not met as evidenced by
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Licensee/Administrator will relocate C1 from Level 2 home to Level 4 home. New address and contact infomration will be provided to LPA by POC date.

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Based on LPA’s interviews, inspection and record review, the licensee did not comply with the section cited above by accepting C1 (Level 4) into a Level 2 home without conducting a proper assessment, which poses a potential health, 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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/06/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20250306162853

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:
03/12/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christine Cheng, Administrator TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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2
3
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5
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9
Staff did not provide transportation assistance according to the resident's admission agreement
INVESTIGATION FINDINGS:
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At 10:00am, Licensing Program Analyst (LPA), Angela Panushkina, arrived at Fairheaven Home 4 in response to the above-mentioned allegation. LPA met with the Administrator and explained the reason for the visit.

At 10:05am, LPA requested client and staff roster. At 10:10am requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Individual Program Plan (IPP), Approved Transportation schedule relevant to the investigation. At approximately 10:15pm, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:20pm – 12:30pm, LPA conducted an interview with the Licensee, Administrator, three (3) staff and five (5) out of five (5) clients.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250306162853
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 4
FACILITY NUMBER: 197610504
VISIT DATE: 03/12/2025
NARRATIVE
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Allegation: Staff did not provide transportation assistance according to the resident's admission agreement

It was alleged that one (1) out of five (5) clients experienced difficulty in obtaining assistance with transportation to and from medical consults. To investigate this allegation, LPA conducted an interview with the Licensee, Administrator and two (2) staff members. All parties interviewed denied the above allegation and informed the LPA that the facility always has a car and a driver available, and they never refused any transportations. LPA was also informed that one (1) client prefers the transportation to be provided by the family/friend, instead. LPA conducted an interview with five (5) clients and all clients interviewed expressed to concerns regarding this allegation. Interview with two (2) clients also confirmed that they prefer their family member to provide a transportation for their medical appointments. Therefore, based on interviews 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: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5