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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197690045
Report Date: 10/05/2021
Date Signed: 10/05/2021 03:14:34 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
10/01/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211001081014
FACILITY NAME:ELEVATION BEHAVIORAL HEALTHFACILITY NUMBER:
197690045
ADMINISTRATOR:LORI SCOTTFACILITY TYPE:
772
ADDRESS:3855 BRUNSTON COURTTELEPHONE:
(818) 877-0934
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 3DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Danielle HageTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Uncleared adults providing care and supervision to clients.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived at unannounced for an initial complaint visit. The LPA met with Danielle Hage and explained the reason for the visit. During today’s visit, the LPA conducted a tour at 12:51 a.m., interviewed staff at 1:27 p.m. and 1:35 p.m., and reviewed documents.

Regarding the allegation, it was alleged that there were uncleared adults working at this location. At.2:30 p.m., the LPA spoke with the Operations Manager regarding whom was working at this location. The LPA compared the list to the Department clearance list and identified four employees (Staff #1, Staff #2, Staff #3, Staff #4) were working either without a clearance transfer or the clearance status was set to ‘Pending’. Based on interview and records review, this allegation is deemed Substantiated at this time. The facility was cited for this violation on 08/03/2021; additional civil penalties assessed.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
Exit interview conducted, today's reports and appeal rights were reviewed and issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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 29-AS-20211001081014
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: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
81019(e)(1)
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81019(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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The Licensee agrees to do the following:
1. Submit appropriate paperwork the four staff and confirm that the staff are associated to the facility prior to allowing them to return to work.
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Based on record review, the Licensee did not comply with the section cited above, as there were four staff (S1, S2, S3, S4) working whom were not associated to this facility, 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3