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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197690036
Report Date: 03/25/2026
Date Signed: 03/30/2026 12:24:18 PM

Unsubstantiated


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
08/01/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20250801083558
FACILITY NAME:ELEVATIONSFACILITY NUMBER:
197690036
ADMINISTRATOR:CHEROKEE WATKINSFACILITY TYPE:
772
ADDRESS:3836 KANAN ROADTELEPHONE:
(858) 695-4069
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:6CENSUS: 5DATE:
03/25/2026
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ama Reyes, Program Director & Greg AllenTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not follow residents' needs and services plan
Staff did not distribute residents' medications as prescribed
Staff do not provide residents with activities
Staff did not ensure that residents' dietary needs were met
Staff unreasonably searches residents' belongings
INVESTIGATION FINDINGS:
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This is an amended report to reflect correct allegation. Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final finding for the above allegations. During today’s visit, LPA met with staff, Ama Reyes, Program Director and Greg Allen. Reason for the visit was explained.

On 08/01/2025, the Department received a complaint regarding the above allegations. During the initial complaint visit on 8/07/2025, LPA met with staff and explained the reason for the visit. Between approximately 11am to 2:15pm, LPA conducted physical plant tour, interviewed 6 (six) clients, 2 (two) staff and also reviewed and obtained copies of pertinent documents relevant to the investigation. Additional staff interviews were conducted on 11/22/2025.

Following is the summary of the allegations and investigation finding: To investigate the complaint allegations, LPA reviewed client roster, centrally stored medication records, medication administration records, and needs and services plans. (Continue to LIC9099c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
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 4
Control Number 29-AS-20250801083558
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: 03/25/2026
NARRATIVE
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LPA also reviewed facility program plan, admission records, policy and procedures. In addition six (6) clients and four (4) staff were interviewed.

Regarding allegation “Staff do not follow residents' needs and services plan”: Information was received that staff do not provide residents with therapy/therapist and do not monitor clients’ vitals and blood pressure. Records reviewed and interviews conducted with staff confirmed that all clients are seen by therapists seven days a week. Clients attend group sessions and individual sessions throughout the week; clients also meet with psychiatrist and or a nurse once a week and more frequently as needed. Six (6) out six (6) clients interviewed verified that they do receive therapy and meet with a psychiatrist once week. Staff interviews and records reviewed verified that the needs and service plans are developed upon admission with client and reviewed by the case manager with the clients if needed during their residence. Needs and services plans reviewed for current and previous clients attending the program observed complete. Several attempts made to reach reporting party was unsuccessful. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff do not follow residents' needs and services plan” is deemed Unsubstantiated at this time.

Regarding allegation “Staff did not distribute residents' medications as prescribed”. Information was provided that on 6/22/2025 facility had a power outage and clients were not given their medications. Interviews conducted with staff and records reviewed revealed that the power shut-off was scheduled by Southern California Edison for 6/22/2025 from 8pm-5am. According to staff, clients’ daily living and activities were not interrupted since it was scheduled shut-off; clients’ received there meals and medications with no issues. Several attempts made to reach the reporting party were unsuccessful. No issues reported during the time of the scheduled power shut-off by any client or staff. Six (6) out of the six (6) clients interviewed did not report any issues with receiving prescribed medication. Medications are centrally stored and not accessible to anyone but staff in charge of the medications. Clients confirmed that they have not missed any prescribed medications at this time. During the initial visit and subsequent visit all clients’ medications observed centrally stored and inaccessible. The facility medication administration log reviewed verified that all prescribed medications are provided accordingly as prescribed. No discrepancies observed during initial and subsequent visit. (Continue to LIC9099c)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250801083558
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: 03/25/2026
NARRATIVE
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Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations “Staff did not distribute residents' medications as prescribed” is deemed unsubstantiated at this time.

Regarding allegation, “Staff do not provide residents with activities”: Information was received that staff posts a schedule of events for clients however, staff do not follow the schedule. It was also reported that staff do not provide clients with activities and internet services and that staff leave clients sitting in their rooms "to their own devices." During the initial visit LPA observed the activities schedule posted; staff interviewed reported that the schedule is followed but change sometimes; outing scheduled is decided by clients and staff that day depending on clients’ preferences. Six (6) out of six (6) clients interviewed reported being satisfied with the activities provided. Clients expressed that they participate if they want and that they are not forced. Clients confirmed that they do have access to the internet. Clients expressed that they have a busy schedule and basically only spend time in their room between therapy sessions and when they go to bed. Several attempts made to reach reporting party were unsuccessful. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation “Staff do not provide residents with activities” is deemed Unsubstantiated at this time.

Regarding allegation, “Staff did not ensure that residents' dietary needs were met”: Reporting party did not provide any specific information about this allegation but that the facility had a power outage on 6/22/2025 and clients were not served any food or beverages. Interview conducted with staff and records reviewed revealed that on 6/11/2025 facility received a notice from Southern California Edison regarding planned power outage/shut-off scheduled for 6/22/2025 in the area for maintenance/repairs. Staff reported that since it was scheduled in advance they were able to plan accordingly and clients’ daily living activities were not interrupted. Records reviewed did not show any complaints/issue reported from any of the attending clients or staff for the month of 6/2025. Clients interviewed on 8/7/2025 reported that they are satisfied with the meals served. Clients did not report any unmet needs related to facility meal planning. Client records reviewed did not identify any client on a specific prescribed diet. All clients attending 6/2025 and 8/2025 were on regular diets; no prescribed diet. (Continue to LIC9099)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20250801083558
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: 03/25/2026
NARRATIVE
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 Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations “Staff did not ensure that residents' dietary needs were met” is deemed unsubstantiated at this time.

Regarding allegation, “Staff unreasonably searches residents' belongings”: Information was provided that staff unreasonably search residents' belongings; that staff search residents' personal belongings for no reason and without notice and consent. Staff interviewed and records reviewed revealed that the facility program plan has a contraband policy and this information is provided to clients at admission. According to staff all clients are aware of the policy and consent upon admission. Staff reported they conduct random unannounced room search to ensure clients and staff safety. Six (6) out of six (6) clients interviewed stated that they are aware of the program/admission policy and that staff do conduct random unannounced searches of client rooms for any items that could pose a physical risk. Staff reported that the search/room check is not unreasonable, and clients do consent upon admission. Several attempts made to reach reporting party was unsuccessful. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations “Staff unreasonably searches residents' belongings” is deemed unsubstantiated at this time.


Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4