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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 01:13:44 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
04/10/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20250410081057
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:
01:20 PM
ALLEGATION(S):
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Staff violated clients personal rights
Staff engaged in inappropriate conversations while in front of clients in care.
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 4/15/25, LPA toured the facility, interviewed Lead Staff 1 (LS 1) who has since resigned, 1 client, and 3 staff, and requested copies of various documents. Additional interviews with staff and witnesses were conducted via phone calls on 4/17/25, 4/18/25, and 4/19/25. Visits for other complaints were conducted on 4/17/25, 7/31/25 and annual done on 10/30/25.
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 7
Control Number 29-AS-20250410081057
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 allegation – Staff violated clients personal rights.
It was alleged that on 04/03/2025, a client (C1) had personal property (a guitar) taken away by lead staff. It was also alleged that staff threatened to remove C1 from the facility. Additionally, it was alleged that the facility withholds clients’ cigarettes and access to outings as a form of behavioral control, only allowing access if clients complete assigned daily tasks.

Interviews with the LS 1, facility staff, and outside supports for C1 revealed that the guitar in question was provided by an outside clinician and intended to be given to C1 upon discharge. However, the LS 1 gave the guitar to C1 in error on the morning of 04/03/2025. Upon realizing the mistake, the LS 1 retrieved the guitar. When C1 later requested the guitar, the LS 1 refused, which led to an escalation in behavior and raised voices from C1 and LS 1. The LS 1 reported feeling unsafe during the interaction.
LPA reviewed C1’s personal property inventory, which listed the guitar as belonging to C1. Additionally, C1’s intake documentation noted that playing music is a calming strategy for them when upset.

Interviews with lead and support staff confirmed that clients’ cigarettes are stored in the staff office and distributed during designated “outside break times.” Staff also acknowledged that access to cigarettes and outings is sometimes contingent upon clients completing daily expectations, such as attending groups.

Documents collected during the investigation included:
A calendared schedule of events with a notation on the bottom of the calendar stating: “Outside breaktime only if client attended previous group and arrived on time.” And stating: “Community time from 2–4 p.m. if client attended all groups on time the previous day.” A document titled “Agnes CRT FRESH AIR/Smoke Break SCHEDULE” listing ten 15-minute breaks and one 2-hour break. A staff communication dated 01/29/2025 stating: “Effective immediately, clients must keep their cigarettes in the hub… they need to turn them into us when they purchase new ones.” An additional communication from the administrator dated 2/1/25 stating: “…remind them if they continue to share… they will have their smoke breaks revoked for the entire day, no exceptions.”

Based on interviews and documentation reviewed, the preponderance of evidence supports the allegation that C1’s personal property was withheld. Additionally, facility practices regarding access to cigarettes and outings appear to be used as behavioral incentives, which may restrict client rights. Therefore, the allegation is SUBSTANTIATED.
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 7
Control Number 29-AS-20250410081057
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 allegation – Staff engaged in inappropriate conversations while in front of clients in care.

It was alleged that on 4/3/25, during an escalating incident involving Client 1 (C1), LS 1 discussed C1’s personal health information with an administrator via speakerphone, in the presence of other clients and staff.

There were three complaints received regarding the safeguarding of client confidentiality at this facility between April and July of 2025.

LPA conducted interviews with the LS 1 involved and three witnesses to the events of 4/3/25. The LS 1 denied discussing client information publicly. However, all three witnesses stated that the LS 1 was on a speakerphone call with an administrator in the LS 1’s office, and at one point exited the office with the phone on speaker to follow C1, continuing the conversation in a common area.
An additional client interviewed reported that discussions about client care occurred during their stay at the facility. Other clients interviewed during LPA’s visits stated they typically do not hear staff discussing personal matters outside of the designated staff area (referred to as the “hub”). However, they noted that the hub door is often left open, and conversations about appointments and support services can sometimes be overheard. Clients did not feel this was done intentionally.

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,” contains a whiteboard displaying client initials, room numbers, and diagnoses. This was noted as being moved and covered as of 10/31/25. The 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.

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. Page 3 Continued on 9099-D
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: 5 of 7
Control Number 29-AS-20250410081057
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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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 observations, interviews, and records, the preponderance of evidence supports the allegation. Therefore, the allegation is SUBSTANTIATED.

Exit interview conducted, copy of appeal rights printed and report provided.
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 7
Control Number 29-AS-20250410081057
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
12/01/2025
Section Cited
CCR
81072(a)(1)(3)(16)
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81072 Personal Rights (a)Each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. (3)To be free from corporal or unusual punishment…intimidation…threat…or other actions of a punitive nature…(16) To possess and use his/her own personal items…This requirement is not met as evidenced by:
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Facility has worked in coordination with, Patient Rights through Santa Barbara County Behavioral Wellness Department. Training was conducted after the incident and is ongoing.
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Based on observation and interviews the licensee did not comply with the regulation above when they took away items belonging to clients, raised voices at C1, and were punitive with clients smoke breaks and possessions. This poses a potential health and safety risk and violates personal rights 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: 4 of 7
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
04/10/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20250410081057

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:
01:20 PM
ALLEGATION(S):
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 Staff does not ensure clients are provided with services for treatment
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 4/15/25, LPA toured the facility, interviewed team lead, 1 client, and 3 staff, and requested copies of various documents. Additional interviews with staff and witnesses were conducted via phone calls on 4/17/25, 4/18/25, and 4/19/25. Visits for other complaints were conducted on 4/17/25, 7/31/25 and annual done on 10/30/25.

On the allegation – Staff does not ensure clients are provided with services for treatment
Unsubstantiated
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: 6 of 7
Control Number 29-AS-20250410081057
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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It was alleged that clients are missing appointments for services they need, and that clients are being discharged without appropriate support.

LPA investigated whether the facility is meeting its obligations to provide individualized, consistent, and appropriate treatment services, including support for appointments and discharge planning.

An interview with an outside agency support service indicated that Client 1 (C1) was told they must meet with lead staff before attending their next appointment, and that failure to do so could result in removal from the program. Staff interviews conducted on 4/15/25 confirmed that C1 attended a morning appointment but missed an afternoon appointment in Santa Barbara related to housing and case management. Staff reported that C1 refused to attend the second appointment due to an unresolved disagreement with lead staff regarding personal property (a guitar).

LPA reviewed C1’s discharge documentation and, on 10/31/25, reviewed records for other clients discharged around the same time. Records indicated that some clients discharged abruptly, which limited staff’s ability to complete treatment and discharge planning. Other records reflected successful discharges with appropriate support and referrals.

While there is documentation of one missed appointment related to a client conflict, there is insufficient evidence to support a pattern of clients routinely missing appointments due to staff refusal or program failure. Additionally, while some discharges were incomplete due to client departure, this does not appear to be the result of staff negligence or failure to provide support, but rather the nature of client-initiated discharges.

Based on LPA’s observations, interviews, and documentation review, the preponderance of evidence standard has not been met. Therefore, at this time, the allegation is UNSUBSTANTIATED.
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: 7 of 7