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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197690036
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:32:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20210903123753
FACILITY NAME:ELEVATIONSFACILITY NUMBER:
197690036
ADMINISTRATOR:JORDAN ARONOFFFACILITY TYPE:
772
ADDRESS:3836 KANAN ROADTELEPHONE:
(858) 695-4069
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:6CENSUS: 6DATE:
04/26/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christina Hemming - Operations SupervisoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Knives are accessible to clients in care
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Christina Hemming - Operations Supervisor and explained the reason for the visit.

On 09/07/2021, between 10:30am – 1:30pm, LPA conducted an unannounced complaint visit where LPA met with Operations Director Danielle Hage, interviewed clients, staff as well as reviewed and obtained copies of pertinent documents relevant to the investigation. On 04/20/2023, LPA conducted an unannounced subsequent visit on a separate complaint investigation and conducted physical plant at approximately 10:15am as well as interviewed staff, parties with knowledge of the situation between 1pm – 4pm. Additionally, at approximately 11am, LPA reviewed and obtained additional pertinent documents relevant to the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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 5
Control Number 29-AS-20210903123753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036
VISIT DATE: 04/26/2023
NARRATIVE
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continued from 9099

It was reported that knives are accessible to clients in care, as it was alleged that Client 1 (C1), picked up a knife and held it up for approximately 10 minutes. Interviews conducted with former clients and staff revealed that Client 1 (C1) and Client 2 (C2) , observed a knife left out on the kitchen counter on one occasion during their stay at the facility. Interviews further revealed, C1 stood in front of the knife for approximately 5 to 10 minutes , while staff were observed having a conversation in the backyard. As staff reentered the facility, C1 and C2 exited the kitchen. During visits on 09/07/2021, 10/05/2021, and 04/20/2023, LPA did not observe any knives or sharp objects accessible to clients in care. Based on information obtained over the course of the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that knives are accessible to clients in care has been deemed Substantiated at this time.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D).

Exit interview conducted. Citation issued. Appeal Rights discussed and copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210903123753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2023
Section Cited
CCR
81087(l)
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81087 (l) The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions, and poisons are stored where inaccessible to clients. This requirement was not met as evidence by:
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Licensee agreed to submit a statement of understanding, detailing how the facility will maintain compliance of 81087(l) and submit to LPA via email by COD 04/27/2023.
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Based on interviews, the licensee did not ensure knives were kept inaccessible to clients which poses an immediate health and safety 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20210903123753

FACILITY NAME:ELEVATIONSFACILITY NUMBER:
197690036
ADMINISTRATOR:JORDAN ARONOFFFACILITY TYPE:
772
ADDRESS:3836 KANAN ROADTELEPHONE:
(858) 695-4069
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:6CENSUS: 6DATE:
04/26/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christina Hemming - Operations SupervisoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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2
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9
Unqualified staff working at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Christina Hemming - Operations Supervisor and explained the reason for the visit.

On 09/07/2021, between 10:30am – 1:30pm, LPA conducted an unannounced complaint visit where LPA met with Operations Director Danielle Hage, interviewed clients, staff as well as reviewed and obtained copies of pertinent documents relevant to the investigation. On 04/20/2023, LPA conducted an unannounced subsequent visit on a separate complaint investigation and conducted physical plant at approximately 10:15am as well as interviewed staff, parties with knowledge of the situation between 1pm – 4pm. Additionally, at approximately 11am, LPA reviewed and obtained additional pertinent documents relevant to the investigation.
It was reported that Unqualified staff are working at the facility, as it was alleged that Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) were not qualified to be in their positions.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210903123753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036
VISIT DATE: 04/26/2023
NARRATIVE
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Continued from 9099-A

LPA’s records review of training documents for S1, S2 as well as (3) other employees revealed that the facility staff have sufficient training as required by Title 22 Regulations. Interviews with current staff revealed that S3 is not an employee of Elevations , but worked for a vendor billing company and did not have any direct contact with the clients in care. Based on information obtained over the course of the investigation, the department does not have sufficient evidence to determine this allegation occurred. Therefore the allegation that Unqualified staff are working at the facility has been deemed Unsubstantiated at this time.


Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5