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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802124
Report Date: 10/24/2024
Date Signed: 10/24/2024 04:20:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
10/17/2024 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20241017001229
FACILITY NAME:ST. ANDREW'S RESIDENCE 1FACILITY NUMBER:
425802124
ADMINISTRATOR:ABATA, CHARMAINEFACILITY TYPE:
735
ADDRESS:1913 BIRCH STREETTELEPHONE:
(805) 937-8273
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 6DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
04:02 PM
MET WITH:Frixton Abata, Asst.AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Client sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Erika Miller (Miller), conducted an unannounced initial complaint visit to the facility above on 10/23/24. LPA Miller was accompanied by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QA) Miguel Magaña (Magaña). Kathy Pyper (Pyper), interpreter was present and provided communicative sign language. LPA Miller and QA Magaña met with Frixton Abata, assistant administrator. LPA Miller and QA Magaña interviewed staff and residents.

On 10/24/24 LPA Miller met with Frixton Abata, Assistant Administrator and issued final findings on the allegations above. RP alleges that Resident 1 (R1) who is non-verbal, had an unexplained scratch across forehead.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 2
Control Number 29-AS-20241017001229
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST. ANDREW'S RESIDENCE 1
FACILITY NUMBER: 425802124
VISIT DATE: 10/24/2024
NARRATIVE
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R1 explained that while retrieving mail, they scratched their forehead on an overgrown vine that grew from the neighbor’s yard and over the fence. R1 prefers to use bedroom door to walk to the mailbox, instead of using the front door. R1 reported injury to staff and was treated immediately. R1 stated they did not sustain any other injury. R1 lifted shirt during interview, to show no injury or scratches on abdomen. R1 further stated they feel safe, the food is good, and staff treat them nicely. R1 stated staff provide help as need and provide medicine.

Multiple staff stated that injury was reported and treated immediately. In addition, multiple staff stated that overgrown vines were trimmed back in an effort to avoid a repeat incident.

Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An Exit interview conducted, and a copy of this report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2