565850244-7-8-2025-29-AS-KLOZ-DK485P-20250730221304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850244
Report Date: 07/08/2025
Date Signed: 07/08/2025 10:07:19 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/13/2025 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20250613103322

FACILITY NAME:	PALS SKILLS CENTER		FACILITY NUMBER:	565850244
ADMINISTRATOR:	POURAN MOUSAZADEH		FACILITY TYPE:	775
ADDRESS:	1310 E MAIN STREET		TELEPHONE:	(562) 489-3859
CITY:	SANTA PAULA	STATE: CA	ZIP CODE:	93060
CAPACITY:	30	CENSUS: 5	DATE:	07/08/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jesus Landeros		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff incorrectly dispensed medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Esther Cortez along with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Katy Robison conducted an unannounced complaint visit for the above allegation. Upon arrival, LPA met with the Program Director (PD), Jesus Landeros, and explained the reason for the visit. Entrance interview conducted. The facility was experiencing a power outage.

On 06/18/2025, the LPA interviewed the Program Director, four (4) staff, three (3) consumers, conducted a medication review, file review and collected pertinent documents relevant to the investigation. On 06/18/25, the LPA interviewed one (1) employee from C1's home telephonically. During today's visit the LPA attempted to interview Consumer 1 (C1).

The report will continue on LIC9099-C, 2nd page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

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-20250613103322

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALS SKILLS CENTER	FACILITY NUMBER: 565850244
	VISIT DATE: 07/08/2025

NARRATIVE

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Regarding the allegation, “Staff incorrectly dispensed medication”; it is alleged that on 06/12/25, Client 1 (C1) was given a brown, blue, white and yellow pill by Staff 1 (S1) even though they are not supposed to be administered any medication at their Day Program. Interviews with the Program Director and four (4) staff (including staff that were assigned to C1 on 06/12/25), revealed that C1 does not currently take any medications at the Day Program, all denied giving C1 any medications and all denied witnessing any other staff giving C1 any medication. Staff further revealed that C1 previously took prescribed medications at the Day Program but were not able to provide the date of when that stopped. Staff stated that if they ever saw any staff providing C1 or any client that they know is not supposed to be taking medication at the day program, they would question them and report it. File and medication review did not reveal any indication of medication currently being administered to C1, only two (2) consumers currently take medications, and the LPA did not observe any brown, blue, or yellow pills during medication review. Additionally, file review and staff interviews revealed that there is no staff at the Day Program with the name provided for S1. During today’s visit the LPA attempted to interview C1, however was not successful. Interviews with consumers revealed that C1 used to take medications at the Day Program in the beginning at the year but have not seen C1 take medications recently. Furthermore, interview with a staff from C1’s home confirmed that C1 used to take medications at the day program, however they stopped around February or March and do not have any concerns about C1 being administered any medications at their Day Program. Based on the information gathered, this allegation is deemed Unsubstantiated at this time.

No deficiencies were cited. Exit interview conducted and report issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

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