197610546-6-4-2026-31-AS-TAGD-DV4MX8-20260616095932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610546
Report Date: 06/04/2026
Date Signed: 06/04/2026 01:26:10 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.RO, 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
05/28/2026 and conducted by Evaluator Angelica Segovia

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260528095441

FACILITY NAME:	VICTORY BAY RESIDENTIAL SERVICES I, LLC		FACILITY NUMBER:	197610546
ADMINISTRATOR:	KIERSTEN PENNINGTON		FACILITY TYPE:	772
ADDRESS:	19667 TRULL BROOK DR.		TELEPHONE:	(747) 265-6038
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 5	DATE:	06/04/2026
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Kiersten Pennington- Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility staff did not follow client's care plan which resulted in financial lost.

INVESTIGATION FINDINGS:

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On 6/04/2026 at approximately 9:15 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Administrator, Kiersten Pennington arrived shortly after to assist with today’s visit.

To investigate the allegation(s), at approximately 09:40 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation such as but not limited to: Admission Agreement, Needs/Services, and Client’s handbook. From 10:30 AM to 1:30 PM, LPA attempted interviews with three (3) clients (C1- C3), three (3) staff members (S1-S3) and conducted record review.

(continue to LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

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-20260528095441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VICTORY BAY RESIDENTIAL SERVICES I, LLC	FACILITY NUMBER: 197610546
	VISIT DATE: 06/04/2026

NARRATIVE

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Regarding the allegation: Facility staff did not follow client's care plan which resulted in financial lost. It was alleged staff did not follow C1’s treatment plan which resulted in C1's financial lost when purchasing items for multiple clients. To investigate the allegation, LPA attempted to interview three (3) clients and three (3) staff members. LPA attempted to interview C1, C2 and C3 but they no longer reside at the facility and could not be contacted. LPA’s interview with S1 revealed C1 had attended a community outing with two (2) other clients (C2, C3) and one (1) staff member (S3). S1 revealed the outing was approved for the movies but instead the clients “pivoted” to a non-approved outing to the mall resulting in C1 purchasing items for C2 and C3. S1 revealed due to the incident, S3 was spoken to where an investigation was conducted by the Human Resources department (HR) resulting in termination. LPA’s interview with S2 correlated S1’s interview. S2 revealed S3 should have stopped C1, and the outing should have been ended. S2 stated, “It is the responsibility of the staff to ensure they are not spending amongst their needs”. LPA attempted to interview S3, but they no longer work at the facility.

LPA conducted a record review of C1’s file. LPA’s record review of C1’s diagnosis revealed C1 to have a range of psychological health conditions including “impulsivity” which requires them to have, “…24-hour structure, therapeutic intervention, and monitoring to support stabilization and prevent further decompensation”. Further record review of C1’s “Receipt of Client Handbook and Orientation Guide” revealed one of the community guidelines to state, “Residents are not permitted to borrow money, lend money, or purchase gifts for residents or staff”.

Additionally, LPA’s record review of the Facility’s Program Design revealed, “It is the policy…clients who are capable of leaving the premise with or without supervision to do so, so long as…those clients are capable of managing their mental health…”. When questioned if C1 could leave the facility without staff supervision, both S1 and S2 denied their ability in doing so. LPA’s record review of C1’s Admission Agreement revealed C1, “…completed an assessment…and has been deemed appropriate for admission…” into the facility where they would be provided with, “…24-hour-a-day non-medical care and supervision…”. Further record review of C1’s treatment plan dated (4/06/2026) revealed them to have difficulty with, “…socialization and self-advocacy…” where interventions of self-regulation skills were notated.

Based on interviews and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given and a copy of this report was provided to the Administrator

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260528095441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VICTORY BAY RESIDENTIAL SERVICES I, LLC	FACILITY NUMBER: 197610546
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/18/2026 Section Cited CCR 81078(a)	1 2 3 4 5 6 7	81078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs The requirment was not met evidenced by:	1 2 3 4 5 6 7	The Licensee/Administrator will email LPA Segovia an in-service training with staff regarding supervision and intervention by POC due date. POC due date: 6/18/2026
	8 9 10 11 12 13 14	Based on interviews and record review, C1's treatment plan revealed them to have difficulty with "Self-advocacy" yet staff allowed them to purchase items for other clients. This poses a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

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