<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197690036
Report Date: 09/15/2023
Date Signed: 09/15/2023 10:50:12 AM

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
10/01/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20211001085101
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: 4DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nesha TandonTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee failed to ensure that clients were free from acts of a punitive nature
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Brian Balisi conduced a subsequent complaint visit to deliver final findings for the allegations listed above. During today’s visit, LPA met with Nesha Tandon and explained the reason for the visit.

On 10/05/2021, from 10:30 a.m. – 02:30 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff, residents, reviewed, and obtained pertinent documents relevant to the investigation. On 04/20/2023, LPA conducted interviews with staff while investigating a separate complaint. On 07/13/2023, between 10:30 a.m. to 3:30 p.m., LPA conducted a subsequent complaint investigation. During the subsequent visit, LPA conducted a physical plant tour, interviewed staff, as well as reviewed and obtain copies of additional pertinent documentation relevant to the investigation. Additionally, on 07/13/2023, LPA also conducted interview with Department of Health Care Services Analyst
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
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 7
Control Number 29-AS-20211001085101
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: 09/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continued from 9099

It was reported that “licensee failed to ensure that clients were free from acts of a punitive nature” as it was alleged clients were asked to sign a document stating they would not contact licensing or other agencies to file any complaints, as well as not to slander the facility in the news or social media. Interviews conducted and records reviewed revealed that a “Terms of Refund Waiver” was in fact provided to and signed by two (2) clients. The Refund waiver indicated that a “Refund would be applied to the client if they abided by the following terms: Client agrees to not slander Elevation Behavioral Health or its owner, Dr Priya Chaudhri, on the internet or any other form of media, Client agrees to not initiate in any lawsuit against Elevation Behavioral Health or its owner, Dr Priya Chaudri, Client agrees to not contact the state licensing board to make complaints of any sorts, about Elevation Behavioral Health or its owner, Dr Priya Chaudhri, Client agrees to not make complaints of any sorts to their insurance company, about Elevation Behavioral Health or its owner, Dr. Priya Chaudhri.” Based on information obtained over the course of the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Licensee failed to ensure that clients were free from acts of a punitive nature” has been deemed Substantiated at this time.

Although the allegation was Substantiated, the allegation was cited on a separate report from a separate complaint investigation Complaint Control # 29-AS-20210824100000.

Exit interview conducted and copy of report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
10/01/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20211001085101

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: 4DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nesha TandonTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee failed to have qualified staff working at the facility
Licensee failed to comply with required staffing ratios
Uncleared adults providing care and supervision to clients
Licensee failed to correctly charge clients for services as described in the admissions agreement
Client's room smelled of vomit
Client was allowed to hoard food in their room
Facility retained a client that required a different type of care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Brian Balisi conduced a subsequent complaint visit to deliver final findings for the allegations listed above. During today’s visit, LPA met with Nesha Tandon and explained the reason for the visit.

On 10/05/2021, from 10:30 a.m. – 02:30 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff, residents, reviewed, and obtained pertinent documents relevant to the investigation. On 04/20/2023, LPA conducted interviews with staff while investigating a separate complaint. On 07/13/2023, from 10:30 a.m. to 3:30 p.m., LPA conducted a subsequent complaint investigation, LPA conducted physical plant, interviewed staff as well as reviewed and obtain copies of additional pertinent documentation relevant to the investigation. Additionally, on 07/13/2023, LPA also conducted interview with Department of Health Care Services Analyst
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20211001085101
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: 09/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It was reported that “licensee failed to have qualified staff working at the facility”, as it was alleged that staff are not sufficiently trained to perform their job duties. Interviews conducted and records review reflected that staff are required to do online training through Relias, monthly in-service training and shadowing. Interviews with fourteen (14) staff revealed that each shadowed a more experienced staff during their first few weeks of employment. All staff interviewed also stated they have completed the required online training for their position. Records review of six (6) staff files revealed that each staff have sufficient training as required by Title 22 Regulations. Interviews conducted with five (5) clients in care did not reveal any potential or immediate concerns for staff not being qualified for their job at this time. Based on information obtained during the investigation, the department does not have sufficient evidence to determine this allegation occurred. Therefore, the allegation that Licensee failed to have qualified staff working at this facility has been deemed Unsubstantiated at this time.

It was reported that “Licensee failed to comply with required staffing ratios”, as it was alleged that a staff worked alone on multiple shifts. Interviews and records review reflected that during the time of the complaint there were at least two (2) direct care staff scheduled per shift along with a med tech, therapist, clinicians, administrative staff, and other support staff. Interviews with fourteen (14) staff and five (5) clients revealed that there can be anywhere between eight (8) to ten (10) staff in the facility during the day. Everyone interviewed do not recall a time when there was just only one (1) direct care staff on shift. Interview with five (5) clients further revealed that each did not express any immediate or potential concerns for staffing at this time. Based on information obtained during the investigation, the Department does not have sufficient evidence to prove this allegation occurred. Therefore, the allegation that "Licensee failed to comply with required staffing ratio has been deemed Unsubstantiated at this time.


It was reported that "Uncleared adults providing care and supervision to clients", as it was alleged that there were technicians who have criminal backgrounds and are not legally allowed to work. No staff were specifically named by the complainant. Records review of schedule from the time of complaint up to present day, alongside the Department clearance list revealed all employees on the schedule had sufficient criminal background clearance. Based on information obtained during the investigation, the department does not have sufficient evidence to prove this allegation occurred. Therefore, the allegation that "Uncleared adults providing care and supervision to clients" has been deemed Unsubstantiated at this time.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20211001085101
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: 09/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-C
It was reported that Licensee failed to correctly charge clients for services as described in the admissions agreement, as it was alleged that the licensee was charging the clients up front to stay at this facility, along with billing their insurance. Interviews and records review revealed that there are three (3) scenarios that may occur when clients are admitted, which are “private pay”, “insurance pay” and “hybrid” pay. For clients in the private pay scenario, the client either does not have insurance resources, or their insurance covers zero percent of the cost of admission resulting in the client paying out of pocket. In the “insurance pay” scenario, if the client has met their deductible, their insurance will cover the full cost of admission. In the “hybrid” scenario, if a client has not met their deductible prior to being admitted to the facility, the client is then responsible for paying their deductible before insurance covers the remaining cost. In this case, if a client has met a portion of their deductible, a client would be responsible for the remaining cost of their entire stay at the facility. The cost to client varies in range depending on each client’s deductible that they must meet with their insurance. Records review of Admission Agreement further revealed that clients also have the option to pay out of pocket for additional services, such as acupuncture, massages, hypnotherapy, private yoga, etc. It is notated in the Admission Agreement if a client declines additional services. In addition, if a client decides to sign up for a session after signing their admissions agreement and it is not covered in their treatment plan, then they would have to pay for the service out of pocket. However, the client directly pays the provider of that specific treatment for the additional service, not the licensee. The LPA reviewed admission agreements alongside staff and did not observe any inconsistencies or errors. Based on information obtained over the course of the investigation, the Department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Licensee failed to correctly charge clients for services as described in the admissions agreement has been deemed Unsubstantiated at this time.
It was reported that “C1's room smelled of vomit”, as it was alleged that C1 displayed some behaviors of an eating disorder, which resulted in their room smelling of vomit. Interviews conducted and records reflected that C1 was first admitted to this facility on 07/27/2021, with diagnoses of Major depressive disorder, Generalized anxiety disorder, Obsessive compulsive personality disorder and post-traumatic stress disorder. It was also indicated on tC1's Biopsychosocial Assessment that C1 has a history of Anorexia Nervosa, however C1 stated it was not an issue at the time of their assessment. According to C1, they have not had any behaviors typical with bulimia, such as vomiting, since being admitted. In addition, records review of C1’s medical and psychological assessments conducted from 08/13/2021 to 09/23/2021, revealed C1 continued to deny having any behaviors that were associated with bulimia, such as instances of overeating followed by self induced vomiting, however, C1 did confirm having medical concerns with gastrointestinal diagnoses,
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20211001085101
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: 09/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-C2
which have caused C1 to experience multiple days with symptoms of diarrhea and flatulence. This might have resulted in C1’s room to be malodorous for some staff. The assessment indicated this may have led some staff to believe that the odor of the room was a result of C1 vomiting. LPA's interview with fourteen (14) staff and four (4) other clients in care revealed that clients’ rooms are observed every day at least twice a day and each person interviewed have not observed the smell of vomit anywhere in the facility. LPA's physical plant on the initial visit on 10/05/2021, and again on 07/13/2023, did not reveal any evidence of client’s rooms smelling like vomit. Based on information obtained over the course of the investigation, the Department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Client's room smelled of vomit” has been deemed Unsubstantiated at this time.

It was reported that “client was allowed to hoard food in their room”, as it was alleged that C1 displayed some behaviors of an eating disorder, which resulted in client hiding food throughout their bedroom. Interviews conducted and records reflected that C1 was first admitted to this facility on 07/27/2021, with diagnoses of Major depressive disorder, Generalized anxiety disorder, Obsessive compulsive personality disorder and post-traumatic stress disorder. It was also indicated on the C1's Biopsychosocial Assessment that C1 has a history of Anorexia Nervosa, however C1 stated it was not an issue at the time of their assessment. According to C1, they have not hidden food in their bedroom, however if C1 does not finish their food during mealtime there have been occasions where C1 is allowed to bring whatever is left over to their room in a Tupperware. The leftover food is not stored in their room for more than a day. LPA's interview with fourteen (14) staff revealed that client’s rooms are observed every day at least twice a day and each staff interviewed have not observed any evidence of any clients hoarding food in their room. LPA's physical plant on the initial visit on 10/05/2021 and again on 07/13/2023, did not reveal any evidence of clients hoarding food in their rooms. Based on information obtained over the course of the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that client was allowed to hoard food in their room has been deemed Unsubstantiated at this time.

It was reported facility retained a client that required a different type of care, as it was alleged that C1 displays symptoms aligned with bulimia. Interviews conducted and records review reflected that C1 was first admitted to this facility on 07/27/2021, with primary diagnoses of Major depressive disorder, Generalized anxiety disorder, Obsessive compulsive personality disorder and post-traumatic stress disorder.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20211001085101
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: 09/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-C3

It was also indicated on C1's Biopsychosocial Assessment from 07/28/2021, that C1 has a history of Anorexia Nervosa, however, C1 stated it was not an issue at the time of their assessment. LPA's interview with a Department of Health Care Service Analyst revealed that if a client does not have a primary diagnosis of an eating disorder, then the facility is allowed to admit the client. If the client were to have a primary diagnosis of an eating disorder, then they would recommend treatment in a health care setting that employs a registered dietician and physician. According to C1, they have not had any behaviors typical with bulimia, such as vomiting, since being admitted. In addition, records review of C1’s medical and psychological assessments conducted from 08/13/2021 to 09/23/2021, revealed concerns were brought up to C1 regarding C1’s display of restrictive eating behaviors, which include a person avoiding certain foods and having a restrictive amount of food that they intake. C1 continued to deny having any behaviors that were associated with bulimia, such as instances of overeating followed by self induced vomiting, however, C1 did confirm having medical concerns with gastrointestinal diagnoses, which have caused C1 to experience multiple days with symptoms of diarrhea and flatulence. This might have resulted in C1’s room to be malodorous for some staff. The assessment indicated this may have led some staff to believe that the odor of the room was a result of C1 vomiting. Additionally, interviews conducted, and records reviewed further revealed C1 discharged from the facility on 10/09/2021, due to C1’s continuous display of restrictive eating behaviors. Upon discharge C1 was provided with resources to provide support for C1’s level of care. Based on information obtained over the course of the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that facility retained a client that required a different type of care, has been deemed Unsubstantiated at this time.

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

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7