565850129-4-29-2022-29-AS-DPEA-CDXTR8-20220429145705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850129
Report Date: 04/23/2022
Date Signed: 04/29/2022 02:26:37 PM

Unsubstantiated

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
11/23/2021 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20211123134323

FACILITY NAME:	NEW LIFE GROUP HOME		FACILITY NUMBER:	565850129
ADMINISTRATOR:	NASSANGA, FATUMA		FACILITY TYPE:	735
ADDRESS:	5642 EUNICE AVENUE		TELEPHONE:	(818) 324-9589
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	4	CENSUS: 4	DATE:	04/23/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Fatuma Nassanga		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident sustained multiple unexplained injuries while in care.

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted to this facility. The purpose of the visit is to conclude an investigation initiated on 11/23/2021 by Licensing Program Analyst (LPA) Martha Guzman-Chavez. Upon arrival today LPA met with staff. Introduction conducted and reason for visit was explained. Administrator was contacted and arrived shortly after.
Following is a summary of the investigation:
It was alleged that, on 11/1/2021, reporting party observed five (5) large purplish/black bruises and a small cut on client #1’s (C1) left arm. The largest bruise appeared to be about the size of a donut. It was alleged that someone grabbed C1’s arm. No details specified of who may have caused the injuries, how the injuries were caused, when the incident(s) occurred, or who witnessed the incident. No other details provided. On 11/23/2021 at 3:28pm, LPA Martha Guzman-Chavez conducted an initial 10-day visit, at which time a tour of the physical plant was conducted at approximately 3:32 p.m. to make sure there were no health or safety concerns. During the initial inspection, the LPA reviewed files and obtained copies of pertinent documents relevant to the investigation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211123134323

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: NEW LIFE GROUP HOME	FACILITY NUMBER: 565850129
	VISIT DATE: 04/23/2022

NARRATIVE

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On 03/25/2022 at approximately 11:15a.m. LPA Chochian conducted a physical plant tour of the facility and interviewed clients, and staff. Information gathered during the course of the investigation revealed that C1 was admitted to the facility on 08/21/2021. Prior to admission, C1 was noted to be living with C1’s parents and had a difficult time with transitioning to the facility. C1 was noted to have behaviors such as aggression, property destruction, emotional outbursts and self-injuring behaviors. Information gathered further reflected that on 10/29/21, C1 was not feeling well and was transported to urgent care by facility staff. C1 became aggressive during the urgent care visit and staff had difficulty examining C1. Per interviews, C1 was throwing C1’s self to the ground and became difficult to handle. On 11/01/2021, a bruise was noticed on C1’s right upper arm and was most likely to be due to the aggressive behavior C1 had at the urgent care. Additionally, staff interviews revealed that C1 is very difficult to handle and has aggressive behaviors, breaks things, has emotional and self-injuring behaviors. Moreover, interviews conducted with other facility client revealed that clients were happy and felt safe living in the facility. Clients did not report any mistreatment from staff.

Based on the information obtained, the department does not have sufficient evidence to support the allegation, therefore the allegation of 'Resident sustained an unexplained injury while in care' is deemed unsubstantiated at this time.

Exit interview conducted and copy of today’s report and appeal rights will be emailed to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022

LIC9099 (FAS) - (06/04)

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