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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850129
Report Date: 01/06/2023
Date Signed: 01/06/2023 04:47:08 PM

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
12/30/2022 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20221230164813
FACILITY NAME:NEW LIFE GROUP HOMEFACILITY NUMBER:
565850129
ADMINISTRATOR:NASSANGA, FATUMAFACILITY TYPE:
735
ADDRESS:5642 EUNICE AVENUETELEPHONE:
(818) 324-9589
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 4DATE:
01/06/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Fatuma NassangaTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility staff tie the facility front door handles together to prevent clients from eloping.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Arroyo and Tri-Counties Quality Assurance Specialist (QA) Ryan Landseadel conducted an unannounced complaint investigation for the above allegation at 2:10 pm. Upon arrival, LPA and QA were scanned and greeted at the door by staff and the reason for the visit was explained. The LPA spoke with the Administrator via telephone; however, she is unable to come to the facility at this time. Entrance Interview.

During the inspection, the LPA and QA observed four (4) clients and five (5) staff in the living room. LPA and QA interviewed one staff at 3:50 pm and conducted a resident file review at 2:43 pm.

It was alleged that facility staff tie the facility front door handles together to prevent clients from eloping. It was reported that during a facility visit, a Credible Witness (WC) observed a wire that is used to tie the front door handles together from inside the home to prevent clients from eloping.
Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
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-20221230164813
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: 01/06/2023
NARRATIVE
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Report Continued from LIC 9099...

Evidence provided by a CW displayed facility door was being locked from the inside, which is a personal rights violation. Therefore, based on observation and evidence provided by a credible witness, the allegation of “facility staff tie the facility front door handles together to prevent clients from eloping” is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit Interview Conducted. Appeal Rights Discussed. The LPA read report to the Administrator via telephone and gave staff, Dennis permission to sign report. A Copy of the Report was emailed to the Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20221230164813
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2023
Section Cited
CCR
80072(a)(7)(A)
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80072(a)(7)(A) Personal Rights. (a) each client shall have personal rights which include…not to be locked in any room, building, or facility premises by day or night. The licensee shall not be prohibited by this provision from locking exterior doors and windows…
This requirement is not met as evidence by:
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The Administrator will conduct an in-house training with all staff and submit a Statement of Understanding for regulation to CCL no later than 01/13/2023.
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Based on credible witness observation and pictures obtained, the licensee did not comply with the section cited above as staff was using an object to keep clients from exiting the facility, which poses an immediate health, safety, and 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: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3