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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802138
Report Date: 10/31/2025
Date Signed: 10/31/2025 03:45:41 PM

Substantiated


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
04/16/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20250416101150
FACILITY NAME:TELECARE AGNES AVENUEFACILITY NUMBER:
425802138
ADMINISTRATOR:HANNA DIAZFACILITY TYPE:
772
ADDRESS:116 AGNES AVENUETELEPHONE:
(805) 457-3724
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:10CENSUS: 9DATE:
10/31/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alexandria NealTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee failed to follow Plan of Operation in regards to client services.
Staff failed to provide client services required in their services plan
Staff do not keep clients information confidential.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the above facility to issue final findings. LPA met with Licensee Alexandria Neal Team Lead Unlicensed and explained the purpose of the visit.

During the initial visit on 4/17/25, LPA Rankin interviewed 3 clients, 4 staff, a lead staff (LS 1) who has since resigned, and obtained relevant documents. Additional interviews with staff and witnesses were conducted via phone calls on 4/17/25, 4/18/25, and 4/19/25, 5/22/25 and 7/31/25. Visits for other complaints were conducted on 4/17/25, 7/31/25 and the annual done on 10/30/25. During visit on 10/31/25, LPA interviewed staff and 5 additional clients. A collateral visit to obtain additional documentation was done on 6/3/25.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
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-20250416101150
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: TELECARE AGNES AVENUE
FACILITY NUMBER: 425802138
VISIT DATE: 10/31/2025
NARRATIVE
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On the allegations – Licensee failed to follow Plan of Operation in regards to client services and Staff failed to provide client services required in their services plan.

It was alleged that staff refuse to provide groups on a consistent basis and the facility failed to provide services as outlined in the facility’s program plan and client service plans.

The facility’s approved Plan of Operation states the facility will provide intensive and structured psychosocial recovery services, including a minimum of four group skills-building activities and/or wellness classes daily. The program schedule provided to LPA notes the 4 scheduled groups, but also includes additional daily meetings and movement groups, totaling approximately seven structured activities per day.
Additionally, the Plan of Operation outlines that staff will support Community Support Systems Development by working individually and in groups with residents to build their support networks. This includes facilitating access to peer-based and self-help services, coordinating weekly outings to community resources (e.g., libraries, AA/NA meetings, Peer Support Centers), and linking residents to essential services such as outpatient mental health and substance use treatment, entitlement benefits (e.g., SSI, Medi-Cal, food stamps), primary care, and housing resources to ensure stable post-discharge living arrangements.

LPA conducted multiple visits and interviews with staff, who reported that while groups are part of the daily schedule, they are often unable to complete all planned sessions due to competing responsibilities such as intakes, discharges, transportation, medication administration, documentation, food service preparation, individual assistance for clients needing social security, identification, housing, prompting clients with activities of daily living (ADLs), hourly rounds, pass off reports, and facility upkeep. Staff also noted that scheduled training opportunities, especially in person, have been cancelled due to insufficient staffing coverage. The schedule provides that often it is one Residential Councilor and one Licensed Vocational Nurse (LVN) who are meeting the direct care staff ratio at this facility.

LPA reviewed group sign-in sheets for two separate periods. From 3/15/25 to 4/15/25, only 45 sign-in sheets were provided and from 6/26/25 to 7/30/25, only 47 sign-in sheets were provided. These sheets include the daily meetings and movement groups. Page 2 - Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250416101150
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: TELECARE AGNES AVENUE
FACILITY NUMBER: 425802138
VISIT DATE: 10/31/2025
NARRATIVE
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Additionally, a “Manager Note” dated as “March 2025 through May 2025”, referenced staff failure to complete groups, and client service plans reviewed by LPA identified group participation as a key component of treatment. However, documentation does not support that these services were consistently delivered.
While the facility currently maintains staffing levels that meet minimum licensing ratios, evidence suggests that current staffing may not be sufficient to fully implement the intensive and structured psychosocial recovery services described in the Plan of Operation. Staff interviews and documentation indicate that the volume of required services—combined with operational demands—limits the facility’s ability to consistently provide the level of care and programming it has committed to delivering.

Furthermore, clients are in a short-term program, typically limited to 30 days, which increases operational demands. Staff must quickly assess client needs, develop service plans, and coordinate essential services such as housing referrals, medical appointments, and obtaining identification or benefits through state and federal agencies. These tasks are often time-consuming and complex, requiring significant staff time and coordination, which further impacts the facility’s ability to consistently deliver scheduled group services.

Based on LPA’s observations, staff interviews, documentation review, and the facility’s own program requirements, the preponderance of evidence standard has been met. Therefore, the above allegations are SUBSTANTIATED.

On the allegation – Staff do not keep clients information confidential.
It was alleged that staff talk about people’s private information in the open main office or with the medication room doors open, so clients can hear confidential conversations.

This is the third complaint received regarding the safeguarding of client confidentiality at this facility.

Facility tours were conducted on 4/15/25, 4/17/25, and 7/31/25. During these visits, LPA observed that the main support staff office, referred to as the “hub,” contained a whiteboard displaying client initials, room numbers, and diagnoses. This board was located on the right wall and was visible from the doorway. Photographs of the board were taken on 4/15/25 and 7/31/25. The whiteboard was not covered and could be easily seen during interactions between staff and clients at the hub door. As of 10/31/25 LPA noted that the whiteboard has since been moved and now is not visible from the doorway. Page 3 - Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20250416101150
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: TELECARE AGNES AVENUE
FACILITY NUMBER: 425802138
VISIT DATE: 10/31/2025
NARRATIVE
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Staff interviews confirmed that maintaining confidentiality is challenging due to the hub’s central location and frequent client interactions at the doorway. While staff did not report intentionally discussing confidential information in open areas, they acknowledged the difficulty in preventing conversations from being overheard.

Interviews with management and a review of internal “Manager Note” further confirmed that there have been instances where staff left Protected Health Information (PHI) documents visible when stepping away from the hub. Additionally, it was noted that PHI has been left visible on desks when clients approach the hub door to speak with staff, increasing the risk of unintentional disclosure.

Additional complaints received on 4/10/25 and 7/28/25 raised similar concerns about visible client information and conversations occurring in areas where others could overhear.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited on complaint 29-AS-20250728132138, 81070 Client Records (c) All information and records obtained from or regarding clients shall be confidential. (1) The licensee shall be responsible for safeguarding the confidentiality of record contents. (2)…the licensee and all employees shall not reveal or make available confidential information.

Based on LPA’s observations, staff and management interviews, documentation review, and the recurrence of similar complaints, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

Exit interview conducted, copy of appeal rights and report provided to facility.

Page 4
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250416101150
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: TELECARE AGNES AVENUE
FACILITY NUMBER: 425802138
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
CCR
81022(j)
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81022 Plan of Operation (j) The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so. This requirement is not met as evidenced by:
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Facility will provide a plan of how they will ensure daily groups are scheduled and occurring to support the residents services plans by 11/21/25. Facility will provide sign sheets to LPA for December 1 – 12th to show record collection has been corrected and groups are occurring as required. Recommended management or lead staff have a daily presence at the facility.
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Based on record review and interviews the licensee did not comply with the regulation above when they failed to implement the services outlined in the approved Plan of Operation and client service plans. Specifically, the facility did not consistently provide the required number of daily group skills-building activities and wellness classes, and failed to document service delivery as required This poses a potential 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: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5