197610505-7-9-2024-31-AS-TAGD-DEVRWY-20250318132354

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610505
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:58:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
07/03/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240703151243

FACILITY NAME:	FAIRHAVEN HOME 1		FACILITY NUMBER:	197610505
ADMINISTRATOR:	MORTEL, GRACELA		FACILITY TYPE:	735
ADDRESS:	20601 KITTRIDGE STREET		TELEPHONE:	(818) 274-1809
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 4	DATE:	07/09/2024
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Rosemarie Santos - Staff		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for a client

Staff working without a Criminal Record Clearance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with staff Rosemarie Santos who called the administrator Laila Kulunga and explained the reason for the visit. Ms. Kulunga designated Ms. Santos to sign the report.

LPA conducted physical plant tour at 9:22 AM, requested copies of facility documents relevant to the investigation at 9:52 AM, reviewed documents from 10:00 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Staff did not seek timely medical attention for a client, it was alleged that Resident #1 (R1) had wrist fracture and staff did not see immediate medical attention. LPA's interview today with R1 at 11:43 AM revealed that R1 had a fall and broke R1's wrist while visiting a friend's family member. Further, R1 did not feel so much pain after the fall that they did not call 911 or brought R1 to the hospital. Upon return to the facility however, R1 started to feel the pain but admitted that R1 did not want to go to the hospital at that time. R1 went to the day program the next day but was sent back home due to pain and swelling. (continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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-20240703151243

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIRHAVEN HOME 1	FACILITY NUMBER: 197610505
	VISIT DATE: 07/09/2024

NARRATIVE

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(continued from LIC 9099)

R1 was then brought to the hospital and was treated. LPA's record review today revealed that R1 was brought to the hospital on 06/17/24 and subsequent visits to the doctor for regular check and scheduled for a surgery mid of this month.

Regarding the allegation that there was a Staff working without a Criminal Record Clearance at the facility, it was alleged that Staff #1 (S1) has no background check clearance and was not associated at the facility. LPA's record review today revealed that S1 was fingerprint cleared at the CDSS Guardian website and Licensing Information System (LIS) and was associated at this facility on 07/02/24. LPA's interview with the Licensee representative today at 12:32 PM, revealed that S1 was only an emergency placement because the staff they hired called in and was not able to work on 07/01/24. He stated that he himself brought S1 to the facility at around 6:30 PM and he did not have access to Guardian as he just took over the facility and did not have the password despite his request since February of this year, so he was not able to associate S1 to the facility but stated that S1 was his longtime employee from another NLARC vendored facility that he owned. He did however bring the association papers to the CCLD office at the Woodland hills office the next morning and S1 was then associated at the facility.

Based on the information gathered during this visit, the allegations are deemed unsubstantiated at this time. \

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

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