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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800494
Report Date: 12/09/2021
Date Signed: 05/16/2023 10:17:43 AM

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
04/20/2021 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210420140721
FACILITY NAME:SALLY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565800494
ADMINISTRATOR:KAYHAN MOJABIFACILITY TYPE:
740
ADDRESS:928 CARISSA COURTTELEPHONE:
(805) 384-8043
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 6DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Sara JacksonTIME COMPLETED:
03:26 PM
ALLEGATION(S):
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9
Resident’s death was due to inadequate care and supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced subsequent complaint visit to amend the finding for the above noted allegation. The LPA met with facility designee Sara Jackson and explained the reason for the visit.

This is an amended report, as after further investigation, the complaint findings were changed from Unsubstantiated to Substantiated.

Please refer to complaint number 29-AS-20230504101620 for the complaint report findings.


continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 2
Control Number 29-AS-20210420140721
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: SALLY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565800494
VISIT DATE: 12/09/2021
NARRATIVE
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continued from 9099

This is an amended report.



Please refer to complaint number 29-AS-20230504101620 for the complaint report findings.

Exit interview held and a copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2