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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610572
Report Date: 04/08/2026
Date Signed: 04/08/2026 10:47:32 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.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
01/22/2026 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20260122125743
FACILITY NAME:FREE TO BE PROGAMS - OPPORTUNITIES HOME FOR ADULTSFACILITY NUMBER:
197610572
ADMINISTRATOR:DANIEL MORALESFACILITY TYPE:
735
ADDRESS:6537 WEST AVE. L-7TELEPHONE:
(818) 366-6682
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:4CENSUS: 4DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Daniel MoralesTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not administering medications to residents as prescribed.
INVESTIGATION FINDINGS:
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This is a corrected version of the Complaint Investigation Report (LIC 9099-A) conducted on 01/26/2026. This report supersedes the report dated 01/26/2026 to change the findings from Unsubstantiated to Substantiated. Based on further review, the facility did not have documentation showing whether a PRN medication was administered. Client #1 (C1) denies taking the PRN medication. Staff also deny knowledge of what happened to it.

On 1/26/26 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit to this facility to investigate the above mentioned allegations. LPA met with the Administrator, Daniel Morales who granted access. LPA explained the purpose of this visit.

At entry LPA met with Client#3 (C3). LPA initiated an interview. At approximately 9:48 a.m., LPA conducted a physical plant tour of the facility. While conducting the tour LPA met with another client, Client#2 (C2) who at first refused to be interviewed. (Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
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-20260122125743
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: FREE TO BE PROGAMS - OPPORTUNITIES HOME FOR ADULTS
FACILITY NUMBER: 197610572
VISIT DATE: 04/08/2026
NARRATIVE
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At 10:00 a.m., LPA requested and obtained copies of the following: Register of Facility Clients (LIC9020), facility's Personnel Report (LIC500) and four (4) of four (4) clients' Medical Assessments, Medication Administration Records (MAR), Centrally Stored Medication Records, and Individual Program Plans (IPP). At approximately 10:22 a.m., LPA interviewed the administrator, Staff#1 (S1) and C2. At 10:34 a.m., LPA reviewed four (4) of four (4) clients' centrally stored medication and medication records with the administrator present. At 12:00 pm., LPA initiated an interview with Staff #2 (S2) and Clients #4 (C4). At 1:03 p.m., LPA interviewed Staff #3(S3) by telephone. From 2:30 p.m. to 3:30 p.m., LPA reviewed the PRN or as needed medication for Client#1 (C1) and obtained copies of the facility's 15 Minute Medication check, PRN authorization form and daily notes for C1. LPA also interviewed Staff #4 (S4) and Staff #5 (S5), At 4:20 p.m., LPA interviewed C1.

Allegation: Staff are not administering medications to residents as prescribed. It was alleged that three (3) residents had missing medications in January. LPA's interview with the administrator revealed that medication for C2 was missing during the morning medication pass, however, the medication was delivered to the facility later that afternoon and provided the same day. LPA’s review of the MAR showed that staff had signed the initials for the day in question. According to the administrator, C3 was an emergency placement who had been in and out of hospitals, resulting in inconsistent pill counts. North Los Angeles County Regional Center was aware of this and provided guidance. A review of C1’s PRN medication indicated that one of two PRN medications was administered and documented on 01/05/26, which both staff and the administrator confirmed. LPA also observed that the bubble-pack medication for C1 was missing the dose for 01/06/26. Interviews with the administrator and all five (5) staff members interviewed could not clarify whether the 01/06/26 medication was administered to C1. C1 stated only that they took the PRN medication on 01/05/26. A review of C1’s PRN authorization form showed that C1 is unable to determine their own need for prescription or nonprescription PRN medication and is unable to clearly communicate symptoms. Staff reported that facility policy requires them to contact the administrator for approval before administering any PRN medication.

Based on interviews, the facility was unable to determine whether the missing January bubble-pack medication was administered to C1. Because both staff and the administrator have access to the medication, LPA could not determine when it went missing. Therefore the allegation is deemed Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 1 is cited on the attached LIC9099-D. Exit interview conducted. Copy of report provided to Daniel Morales.
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20260122125743
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: FREE TO BE PROGAMS - OPPORTUNITIES HOME FOR ADULTS
FACILITY NUMBER: 197610572
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2026
Section Cited
CCR
80065(a)
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Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs ... This requirement is not met as evidenced by:
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Licensee has conducted in-service training regarding proper record keeping with staff responsible for assisting residents with self administration of medication and provided a copy of the training material and sign in sheet for training to LPA today. POC cleared today.
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Based on LPAs observation and interviews conducted, C1’s PRN medication was popped from bubble-pack but staff could not confirm if C1 received the medication or not which posed a potential health and safety or personal rights risk to clients 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: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3