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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850243
Report Date: 04/30/2026
Date Signed: 05/12/2026 03:42:20 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
11/12/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20251112083024
FACILITY NAME:LAUREL HEIGHTSFACILITY NUMBER:
565850243
ADMINISTRATOR:JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:13960 PEACH HILL DRIVETELEPHONE:
(805) 292-0700
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY:112CENSUS: 73DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Joey AlvaradoTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility is over charging resident for services not provided
Staff do not ensure residents care needs are being met
Resident is not accorded adequate nourishment resulting in weight loss
Staff did not ensure copies of resident records were provided to residents responsible party
Staff did not ensure resident received medical attention in a timely manner
Resident sustained an unexplained injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit regarding above allegations. Upon arrival LPA met with staff and later with Executive Director (ED) Joey Alvarado. The reason for the visit was explained.

On 11/12/2025, Community Care Licensing Division received the above allegations. On 11/20/2025, LPA conducted the initial complaint visit. During the complaint visit copies of records relevant to the case was requested. LPA met with and interviewed two (2) staff at approximately 3:50 p.m. LPA also toured the memory care unit with staff. Staff were observed assisting residents in the dining and activity area. Attempt was made to speak with Resident #1 (R1) however R1 was agitated and showed signs of aggression. During a cite visit on 2/20/2026, additional staff and random residents were interviewed. LPA reviewed R1’s records including but not limited to care assessments, progress notes, internal incident reports, notification letters to family and admission agreement. (Continue to LIC9099c)

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
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 6
Control Number 29-AS-20251112083024
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
VISIT DATE: 04/30/2026
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Following is a summary of the allegations and investigation finding:
Regarding allegation “Facility is over charging resident for services not provided” – Information was received that the facility overcharged R1 for services not provided for R1 being a level 4 in the memory care unit. It was reported that the facility hired a third party care giver for one-on-one care in addition to the care services facility staff were to provide. According to the reporting party R1 was charged for services facility staff did not provide. Facility staff interviewed and records reviewed revealed that initially R1 was assessed to be a level 1 care and within 2-3 weeks R1’s level of care change to level 3 and soon after requiring level 4 assistance due to requiring one-on-one care. Staff interviews and records reviewed revealed that facility hired staff from third-party agency to provide additional supervision. ED reported that the facility paid for the third party staff for additional supervision for R1. Records reviewed and interviews conducted with staff revealed that the charges for the third party staff were showing on the statements, however reflect paid/credited back by the facility. The credit was confirmed by staff and R1’s responsible person. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility is over charging resident for services not provide” is deemed unsubstantiated at this time.

Regarding allegations “Staff do not ensure resident’s care needs are being met and Resident is not accorded adequate nourishment resulting in weight loss” – Information was received that the facility staff did not provide care services to R1, such as showers, transferring assistance to the bathroom, eating assistance, or medication assistance. Staff interviewed denied the allegation. Staff reported that they provided all ADLs for R1; additional help was hired for supervision since R1 was showing rapid change in level of care; requiring additional one-on-one care due to mental status, fall risk and aggressive behavior. According to staff, despite staff trying to attend to R1’s needs and care R1 was very combative and would decline assistance from staff in dressing, showers and routine hygiene care. During the initial visit LPA observed R1 and other residents dressed appropriately, clean and dry. Staff interviews and records review revealed that R1’s family and physician was kept informed regularly on R1’s condition. Regarding allegation “Resident is not accorded adequate nourishment resulting in weight loss” – Interview with staff and records reviewed revealed that R1 would not sit down for meals and constantly move around; family and physician was aware. Order for ensure was received from the physician; medications were also adjusted. Staff reported that R1’s responsible person would control R1’s medication and choose which to fill and bring to the facility. There was no record of R1’s weight at the time of admission in 3/2025; R1’s weight was documented in 4/2025 (116lb) 10/2025 (104lb) and in 11/2025 (102lb). (Continue to LIC9099c)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20251112083024
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
VISIT DATE: 04/30/2026
NARRATIVE
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According to staff and ED R1 was very combative and aggressive, which made it difficult to assist R1 with ADLs. Records reviewed showed that the family and physician were informed of incidents and provided updated care plans. Staff reported that R1’s responsible person was contacted frequently and informed of every detail to R1’s needs and care. Timeline of events and care plans documented by facility was reviewed. R1 required hire level of care then what facility could provide and R1's responsible person was made aware of the issues following each level of care change assessments.

Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff do not ensure residents care needs are being met and Resident is not accorded adequate nourishment resulting in weight loss” is deemed unsubstantiated at this time.

Regarding allegation “Staff did not ensure copies of resident records were provided to residents responsible party” - Information was received that each time R1's level of care would go up, the facility staff never provided in writing, a copy of what those services were. Interview with staff and facility records reviewed revealed that R1 was admitted to the facility on 3/21/2025; resident’s appraisal completed and signed by facility representative and R1’s responsible person; 30 day assessment completed and signed by facility only. According to staff the assessment was discussed with R1’s responsible person and they refused to sign. Staff reported that they made several attempts to coordinate a meeting with the responsible person and failed. Record of R1’s needs and services plan dated 10/7/2025 and 11/27/2025 observed on file with only facility representative signature. According to staff the service plans were discussed with the responsible person and provided to them for signature however never received. Staff interviews and records reviewed revealed that R1’s level of care change and service needs was discussed with R1’s responsible person. Also progress notes kept by the facility documented communication about R1’s care needs and service plan update with R1’s physician and responsible person from the 30day assessment in 4/2024 to 11/27/2025.

Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not ensure copies of resident records were provided to residents responsible party” is deemed unsubstantiated at this time.

Regarding allegations “Staff did not ensure resident received medical attention in a timely manner and Resident sustained an unexplained injury while in care” –
(Continue to Lic9099c)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20251112083024
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
VISIT DATE: 04/30/2026
NARRATIVE
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Information was received that R1 sustained an injury to foot and a wound on the toe and facility staff ignored it and did not seek medical attention. Interview with staff and records reviewed revealed that on 10/18/25, R1 was observed with a minor injury to right toe and left leg; it was unknown to facility staff how the injury occurred. According to staff the injury to R1’s toe did not require higher medical attention and it was not ignored. Staff reported that R1’s responsible person and physician was notified; first aid was provided to R1’s toe. Staff denied the allegation and reported that R1 was continuously monitored by facility staff and a third party caregiver. Staff reported that R1 had other incidents/injury which required medical attention and was sent to the hospital for evaluation.

Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not ensure resident received medical attention in a timely manner and Resident sustained an unexplained injury while in care” is deemed unsubstantiated at this time.

Exit interview conducted an copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/12/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20251112083024

FACILITY NAME:LAUREL HEIGHTSFACILITY NUMBER:
565850243
ADMINISTRATOR:JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:13960 PEACH HILL DRIVETELEPHONE:
(805) 292-0700
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY:112CENSUS: 73DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Joey Alvarado, Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff dispensed incorrect medications to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a complaint visit regarding above allegation. Following is a summary of the investigation finding regarding allegation: “Staff dispensed incorrect medications to resident in care” – Information was received that the facility staff gave R1 another residents medication (dispensed Sertranline 15 mlg Mirtazpine 15 mlg Samotidine 20 mlg). As a result it was noted that R1 lost the ability to walk the rest of the night. Staff interviews conducted and records reviewed confirmed the medication error. On 4/13/2026, staff gave R1 another resident’s medications. Records reviewed and interviews conducted revealed that R1's family and physician were notified and facility followed physician orders to monitor R1 for any changes. No adverse action noted. Based on the above information gathered although the allegations may be valid, there is sufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff dispensed incorrect medications to resident in care” is deemed substantiated at this time.
Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiency was cited.
Exit interview conducted. Copy of the report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20251112083024
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2026
Section Cited
CCR
87465(a)4
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:
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Executive Director stated that since the incident staff was pulled from med-tech duties provided in-service and retrained on medication management and prior to resuming medtech duties staff was supervised by Health and Wellness Director on 3 medication passes.
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Based on records review, the facility failed to assist resident #1 with medication prescribed and instead, gave resident #1 another resident’s medication which poses an immediate health and safety risk to resident 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: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6