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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610505
Report Date: 08/16/2024
Date Signed: 08/16/2024 01:28:35 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.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 1FACILITY NUMBER:
197610505
ADMINISTRATOR:MORTEL, GRACELAFACILITY TYPE:
735
ADDRESS:20601 KITTRIDGE STREETTELEPHONE:
(818) 274-1809
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 4DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Laila Kulungu - AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility does not have a qualified administrator
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA initially met with staff Comfort Oviri who called the administrator Laila Kulungu who arrived about two (2) hours later.

LPA conducted physical plant tour at 9:48 AM, requested copies of additional facility documents relevant to this investigation at 10:12 AM and interviewed additional residents and staff between 10:30 AM to 11:40 AM. it was alleged that it was unclear who was the administrator at this facility as staff and residents confirmed. LPA's record review on 07/09/24 revealed that the administrator on record at this facility is Gracela Mortel. LPA's interview with the Licensee representative and the supposed current administrator Laila Kulungu revealed that Ms. Kulungu took over as administrator at this facility since 05/16/24. Further review however did not show that there was a change of administrator at this facility, nor the Licensee representative showed any evidence that they attempted to change the administrator on record at this facility. (continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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 3
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: 08/16/2024
NARRATIVE
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(continued from LIC 9099)

Credible witness' interview with three (3) residents on 07/02/04 revealed that three (3) residents verbally confirmed that it was the first time they met Ms. Kulungu. LPA's interview with two (2) residents on 07/09/24 between 11:30 AM to 1:30 AM also revealed that they barely see Ms. Kulungu at the facility.

Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2024
Section Cited
CCR
85604(e)
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All facilities shall have a qualified and The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
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The administrator will ensure that all the credential and requirements of the new administrator will be sent to CCL on or before the POC date. In addition, a schedule of weekly visit of the administrator to the facility will be submitted to CCL on or before the POC date with the statement that this
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This requirement is not met as evidenced by:
Based on LPA record review and interview, licensee did not ensure that there is a designated administrator at the facility and spend sufficient time to run the facility. This poses a potential health & safety risk to the residents in care.
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schedule will be adhered to.

This is an amendement of the 9099-D issued to rectify the regulation.
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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: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3