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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801930
Report Date: 09/28/2020
Date Signed: 10/05/2020 01:20:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NAVITA RESIDENCE YOUNG AVEFACILITY NUMBER:
565801930
ADMINISTRATOR:PRESEEDHA ANDICOTFACILITY TYPE:
740
ADDRESS:2024 YOUNG AVETELEPHONE:
(805) 413-2129
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 3DATE:
09/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:PRESEEDHA ANDICOTTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Desaree Perera initiated Case Management - Incident visit. The purpose of this visit is to follow up on a Report of suspected dependent adult/elder abuse (SOC341) submitted to the department on 09/25/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, todays virtual visit was conducted via FaceTime. Administrator Preseedha Andicot was unable to be at the facility during virtual visits therefore, virtual visit was conducted with staff Christine Mululu at 11:04am.
It was reported that on 09/23/2020, Staff #1 (S1) acted inappropriately in the presence of all facility residents and staff. S2 witnessed the incident and informed facility administrator who initiated an internal investigation on 09/26/2020. S1 resides at the facility and worked at the facility on 09/26 through the morning of 09/28/2020 and was suspended pending investigation outcome.
Telephone interviews were conducted with facility staff on 09/28/2020 between 9:11am and 10:17am. During today's virtual visit, LPA conducted a brief tour of the physical plant at 11:06am and additional interview was conducted with staff at 11:18am and requested additional documentation pertinent to the incident at 12:17pm. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time.

Exit interview conducted with administrator via telephone and report was emailed for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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