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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610531
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:29:55 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
11/27/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20241127154156
FACILITY NAME:A SIWA OASISFACILITY NUMBER:
197610531
ADMINISTRATOR:SZALONEK, FEFACILITY TYPE:
740
ADDRESS:15112 ROXFORD STREETTELEPHONE:
(747) 246-3242
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:6CENSUS: 5DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Patria Dufrenne - DesigneeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are utilizing combination locks on the exits from the property to keep residents in
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan and Licensing Program Manager (LPM) Troy Agard conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA initially met with staff Flordeliz Chico who called the administrator Patria Dufrenne who arrived two (2) hours later.

LPA and LPM conducted physical plant tour at 9:30 AM, requested copies of facility documents at 9:45 and interviewed staff and residents between 9:45 AM to 10:15 AM. It was alleged that the main gate going to and from the facility was locked. LPA and LPM observed during physical plant tour that there were two (2) main gates for the entire compound, supposedly one for ingress and one for egress, the ingress gate however is currently not being utilized leaving one gate for car and pedestrian to use. It was observed that it was locked with a combination pad lock and LPA and LPM's interview with Staff #1 (S1) revealed that they were locking the gate due to a resident of another facility within the compound always getting out to buy alcohol. Based on the information gathered during this visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 2
Control Number 31-AS-20241127154156
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: A SIWA OASIS
FACILITY NUMBER: 197610531
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87468(1)(a)(6)
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(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department
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The designee agreed to remove tha pad lock during the day and put a sensor to ensure that the staff are alerted when a resident is leaving the facility at anytime.
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This requirement is not met as evidenced by:

Based on observation, licensee failed to ensure that the residents are not locked in the premises which poses an immediate health & safety and personal rights risk to the residents 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: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
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