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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850066
Report Date: 01/26/2024
Date Signed: 01/26/2024 09:17:48 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
01/12/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20240112113406
FACILITY NAME:MEADOWGLADE, THEFACILITY NUMBER:
565850066
ADMINISTRATOR:HELO, NICOLEFACILITY TYPE:
735
ADDRESS:6446 MEADOWGLADE DRTELEPHONE:
(805) 530-5301
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY:6CENSUS: 3DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Shadi Heydari BateniTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility staff did not provide food to residents on two occasions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 01/17/2024 by LPA M. Arroyo. During today's visit, the LPA met with Program Director, Shadi Heydari Bateni and Administrator Narine Babikian and the reason for the visit was exlained. Entrance interview.

During the initial visit, LPA Arroyo along with facility staff conducted a plant tour to ensure there were no health and safety concerns at 9:15 a.m., conducted interviews with the Administrator, one staff, and three clients between 1:09 p.m. and 2:10 p.m., conducted a file review at 11:30 a.m., and obtained copies of pertinent documents relevant to the investigation.

(Report Continued on LIC 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
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 3
Control Number 29-AS-20240112113406
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: MEADOWGLADE, THE
FACILITY NUMBER: 565850066
VISIT DATE: 01/26/2024
NARRATIVE
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(Report Continued from LIC 9099...)

It was alleged that facility staff did not provide food to residents on two occasions. It was reported that the facility did not offer clients any food during dinner hours and were encouraged to purchase their own dinner. Records review of facility’s admissions agreement submitted to the Department revealed that on page 17 of 40 under Description of Program, it states “Food, shelter, emotional support, and socialization are provided for clients in the program”. This indicates that the facility will be providing clients with three (3) meals a day as stated per regulations. Interviews conducted with staff and clients revealed that on two (2) separate outings, although snacks were made available to the clients, the usual lunch meal provided by the facility during outings which typically includes a sandwich and/or a wrap, was not provided to the clients. Additionally, staff stated that the clients were provided with an outside meal during the outing to bring back to the facility for their dinner. However, because the clients were not given a meal during the outing, as soon as the clients arrived back at the facility, they consumed the meal under the impression that it was their lunch as it was still early in the day. Furthermore, the PM staff believed that the outside food seen earlier was the client’s designated dinner as it was reported to them. Therefore, when clients inquired about food after 5p.m., they were advised to purchase their own food. Based on the information obtained and reviewed, the Department has enough evidence to support the allegation of “facility staff did not provide food to residents on two occasions”. Therefore, this allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240112113406
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: MEADOWGLADE, THE
FACILITY NUMBER: 565850066
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
80076(a)(2)
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80076 (a)(2) In facilities providing meals to clients, the following shall apply: Where all food is provided by the facility, arrangements shall be made so that each client has available at least three meals per day.... This requirement was not met as evidenced by:
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The Licensee has agreed to do an in-house training with all facility staff pertaining to Regulation 80076 – Food Services and submit proof to CCL by 01/31/2024.
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Based on the information obtained, the licensee did not comply with the section cited above as clients were not provided three meals per day on at least two (2) occasions, which posed a potential health, safety, or personal rights risk to persons 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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3