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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610513
Report Date: 08/06/2025
Date Signed: 08/06/2025 09:45:12 AM

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
08/01/2025 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20250801150110
FACILITY NAME:FAIRHAVEN HOME 3FACILITY NUMBER:
197610513
ADMINISTRATOR:KULUNGU, LAILAFACILITY TYPE:
735
ADDRESS:22743 HAMLIN STREETTELEPHONE:
(818) 274-1809
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Cannta CornwallTIME COMPLETED:
08:55 AM
ALLEGATION(S):
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Staff did not submit incident reports to authorized agencies
INVESTIGATION FINDINGS:
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At approximately 8:30 a.m. on 08/06/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit.

Regarding the allegation "Staff did not submit incident reports to authorized agencies" it was alleged the facility was without electricity between 05/30/25 and 06/02/25. Facility staff relocated clients while awaiting the power to return. It was alleged that the facility did not submit an incident report to notify Community Care Licensing Division (CCLD) or the North Los Angeles County Regional Center (NLACRC) about this incident. This power outage was previously investigated as part of complaint # 31-AS-20250602115622. During that investigation, LPA Reed interviewed staff and clients between 1:30 p.m. and 4:00 p.m. on 06/04/25 and toured the facility inside and out at approximately 2:45 p.m. Interviews with five (05) out of six (06) clients, the administrator, and the licensee confirmed that the facility experienced a power outage and clients had to temporarily relocate.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
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 2
Control Number 31-AS-20250801150110
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 3
FACILITY NUMBER: 197610513
VISIT DATE: 08/06/2025
NARRATIVE
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Interview with the administrator at 3:15 p.m. on 06/04/25 revealed they did not send CCLD or NLACRC an incident report to communicate the power outage to the authorized agencies. LPA issued a deficiency for not submitting incident reports during the annual inspection which occurred on the same day, 06/04/25. Today, LPA conducted a record review of NLACRC’s Corrective Action Plan at 9:00 a.m. and toured the facility at 9:20 a.m. Review of the Corrective Action Plan revealed that the facility was cited by the NLACRC for not submitting an incident report after LPA Reed notified the NLACRC about the power outage. Based on interviews and record review, the facility did not submit an incident report to the required agencies after the June 2025 power outage. Therefore, the allegation is deemed SUBSTANTIATED without deficiency at this time since the facility was previously cited for this violation on 06/04/25.

No immediate health or safety concerns were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2