197610939-4-17-2026-31-AS-MGFS-DVZNB8-20260715101842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610939
Report Date: 04/17/2026
Date Signed: 04/17/2026 02:07:09 PM

Unsubstantiated

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
04/10/2026 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20260410143900

FACILITY NAME:	CAPPS CARE HOME		FACILITY NUMBER:	197610939
ADMINISTRATOR:	FERNANDO, ANGELA		FACILITY TYPE:	740
ADDRESS:	8301 CAPPS AVE		TELEPHONE:	(213) 394-4908
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 5	DATE:	04/17/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Angela Fernando- Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Licensee did not conduct a proper assessment of resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mariana Agban conducted an initial 10-day complaint visit to investigate the above allegation. LPA met with Administrator Angela Fernando and explained the reason for the visit. At approximately 09:35 am, LPA conducted a physical plant tour. LPA requested copies of pertinent information which includes and not limited to Resident Roster, Resident#1(R1) Physician Report, R1 Admission Agreement, and Preplacement Appraisal. On today's visit, LPA interviewed the Administrator, two (2) residents and attempted for three (3) residents.

Regarding the allegation: Licensee did not conduct a proper assessment of resident
It is alleged that Resident #1 (R1) has a wound and may require relocation to another board and care facility or placement in a skilled nursing facility. LPA interviewed the Administrator, who denied the allegation and stated that a pre-admission appraisal was completed for R1 on 04/03/2026.
LPA reviewed R1’s Physician’s Report dated 09/18/2025, which did not indicate the presence of any wounds at the time of assessment. (Continue on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260410143900

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: CAPPS CARE HOME	FACILITY NUMBER: 197610939
	VISIT DATE: 04/17/2026

NARRATIVE

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The Administrator reported that R1 is currently receiving services from a Home Health agency for treatment of a Stage 2 wound. The Administrator further stated that R1’s responsible party was notified of the change in condition and agreed with the plan for R1 to remain in the facility while receiving wound care services. LPA contacted the Home Health agency, which confirmed that R1 has a Stage 2 wound and began receiving services on 04/13/2026.
Additionally, interviews conducted with Resident #2 (R2) and Resident #3 (R3) indicated that pre-admission assessments were completed by the Administrator prior to their admission to the facility.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted,copy of this report signed and delivered.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC9099 (FAS) - (06/04)

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