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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850129
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:49:02 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
10/09/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20231009163151
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:
05/17/2024
UNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Fatuma NassangaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in staff care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. LPA M. Arroyo conducted an initial complaint visit on 10/16/2023, and a subsequent visit on 03/26/2024. On today's visit, LPA Arroyo met with Administrator, Fatuma Nassanga. Entrance interview.

During the initial visit on 10/16/2023, LPA Arroyo conducted a plant tour to ensure there were no health and safety concerns at 3:15 p.m., conducted an interview with the Administrator at 4:25 p.m., and obtained copies of pertinent documents. On 03/26/2024, LPA Arroyo conducted a plant tour at 1:45 p.m. and conducted interviews with two (2) staff members and one (1) client between 2:37 p.m. and 3:10 p.m. LPA Arroyo also conducted telephonic interviews with family members on 03/27/2024 at 9:51 a.m. and 05/06/2024 at 1:37 p.m.

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

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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 2
Control Number 29-AS-20231009163151
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: 05/17/2024
NARRATIVE
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Continued from LIC 9099...

It was alleged that resident sustained unexplained injuries while in staff care. It was reported that Client #1 (C1) was seen with multiple bruises on body including lower and upper chest and bruises and red marks on back as well as on the upper hip. Records review revealed that on C1’s physician’s report dated, 05/12/2023 it indicates C1’s primary diagnosis as autism and it states that “C1 needs constant adult supervision for activities of daily living & care. Judgement is impaired & it may put C1 in harm’s way if C1 is not supervised”. Interviews conducted with staff revealed that C1 has both a rocking chair and a swing which C1 enjoys using often. And although staff supervise C1 at all times, staff stated that C1 can at times become aggressive when playing causing small bruises. Additionally, staff added that prior instances occurred where C1 could not stay put and was becoming very disruptive and destructive. However, C1’s primary care physician (PCP) was contacted and ultimately C1’s medication was adjusted. Interviews conducted with family members revealed that facility staff communicate well with them whether it is via phone call or emails and reported having no concerns with how facility staff assist the clients. Furthermore, during client interviews, client stated feeling safe at home. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “resident sustained unexplained injuries while in staff care", is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. Copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2