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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850347
Report Date: 04/16/2025
Date Signed: 04/19/2025 12:54:53 PM

Substantiated


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
08/23/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240823160942
FACILITY NAME:MOM'S PLACE 3FACILITY NUMBER:
565850347
ADMINISTRATOR:IBIRONKE, YUSUFFACILITY TYPE:
740
ADDRESS:975 VALLEY VISTA DRIVETELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 0DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Yusuf IbirTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff did not refund overpaid rent
Resident sustained unexplained injury while in care

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:10 A.M. The LPA was greeted by Caregiver Kazim Albert. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:35 A.M. facility representative arrived. At 10:37 A.M. Administrator, Yusuf Ibironke, was contacted by phone and informed of LPA’s visit. Administrator was unavailable during today's visit. Administrator stated that she not able come to the facility often due to distance, but authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted.

During today's visit LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At the time of the visit, no residents were observed.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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-20240823160942
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: MOM'S PLACE 3
FACILITY NUMBER: 565850347
VISIT DATE: 04/16/2025
NARRATIVE
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Continued from LIC 9099

LPA Conway conducted an initial complaint visit on 08/27/2024. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. LPA also conducted staff interviews at 11:05 A.M, and 1:15 P.M. At 12:53 P.M., LPA interviewed Administrator via phone.Furthermore, LPA interviewed Reporting Party (RP) on 08/26/2024, 09/17/2024 and on 09/19/2024. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined:

The complaint alleges that staff did not refund overpaid rent, as there was an unauthorized electronic money transfer from Resident #1 (R1) account after they had moved out of the facility.

During the investigation, it was confirmed that on 07/01/2024, an unauthorized electronic money transfer of twenty-four hundred dollars ($2,400) was deducted from Resident’s #1 (R1’s) account by the facility, despite R1 being moved out and their personal belongings removed at the end of 06/2024. The resident’s responsible party (RP) explained that the electronic transfer of money occurred before auto-pay was canceled. Furthermore, the RP stated that on 06/12/2024, a verbal 30-day move-out notice was given to the facility representative. It was mutually agreed that the final payment of $2400 along with the remaining credit of $4122.56 covering June’s rent, would constitute the last payment for R1’s rental obligation. However, an additional $2400 payment was deducted on 07/01/2024 in error by the facility. A billing reconciliation document provided by the facility indicated that the $2400 deduction was applied toward an outstanding balance owed by R1. LPA reviewed records from both the facility and the RP confirming that a $2400 deduction was made on 07/01/2024 from R1’s account. Both the RP and the facility representative confirmed that R1 had moved out and all belongings were removed by the end of 06/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that R1 was charged for rent after R1 moved out the facility. Therefore, the above allegation Staff did not refund overpaid rent” is deemed SUBSTANTIATED at this time.

Continued on LIC 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240823160942
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: MOM'S PLACE 3
FACILITY NUMBER: 565850347
VISIT DATE: 04/16/2025
NARRATIVE
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Continued from LIC 9099-C

Regarding allegation “Resident sustained unexplained injury while in care” It was alleged that R1’s thumb got infected and no one in the facility knew what happened to it. Interview with RP revealed that facility staff was not aware on how R1’s thumb became infected. On 05/15/2024, RP took R1 to urgent care, where antibiotics and an antifungal cream were prescribed. On 08/17/2024, a picture of the infected thumb was provided to Community Care Licensing (CCL). Interviews with facility staff indicated that they recalled seeing an issue with R1’s thumb in May 2024; however, the exact date was unknown. Staff stated that this information was relayed to the Administrator, however, this particular change in condition was not formally documented. The Administrator confirmed that they were unaware of how the infection occurred, but stated that staff took R1 to the podiatrist on 06/03/2024 for a follow-up appointment, where additional antifungal cream was prescribed. The facility was unable to provide a doctor’s visit summary for this appointment. LPA was unable to find daily care notes, unusual incident reports submitted by the facility to CCL and/or any doctor visit summaries in the months of May and June of 2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Resident sustained unexplained injury while in care”, therefore, the allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
08/23/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240823160942

FACILITY NAME:MOM'S PLACE 3FACILITY NUMBER:
565850347
ADMINISTRATOR:IBIRONKE, YUSUFFACILITY TYPE:
740
ADDRESS:975 VALLEY VISTA DRIVETELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Yusuf IbirTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Resident wandered away from the facility due to lack of care or supervision from staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:10 A.M. The LPA was greeted by Caregiver Kazim Albert. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:35 A.M. facility representative arrived. At 10:37 A.M. Administrator, Yusuf Ibironke, was contacted by phone and informed of LPA’s visit. Administrator was unavailable during today's visit. Administrator stated that she not able come to the facility often due to distance, but authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted.

During today's visit LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At the time of the visit, no residents were observed.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240823160942
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: MOM'S PLACE 3
FACILITY NUMBER: 565850347
VISIT DATE: 04/16/2025
NARRATIVE
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Continued on LIC 9099-C

LPA Conway conducted an initial complaint visit on 08/27/2024. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. LPA also conducted staff interviews at 11:05 A.M, and 1:15 P.M. At 12:53 P.M., LPA interviewed Administrator via phone. Furthermore, LPA interviewed Reporting Party (RP) on 08/26/2024, 09/17/2024 and on 09/19/2024. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined:

The complaint alleges that Resident 1 (R1), a dementia resident, walked out of the facility unnoticed through an unlocked door and was later found on the ground in the driveway by staff. During an interview with R1’s responsible person (RP), it was stated that R1 was found on the ground outside the facility. According to the RP, an ambulance was called, and R1 was transported to the hospital, where a CT scan was conducted. Upon request for documentation supporting these events, the RP was unable to produce any records. A review of R1’s service plan dated on 11/14/2023, states under background information, that R1 is “looking for escape all day” and has wandering and sundowning behavior. However, LPA did not observe documentation of a recent hospital visit or records related to this alleged incident. Additionally, During the initial visit, LPA observed that the main gate leading to the street and garage door were opened. During the plant tour, LPA observed two (2) non-ambulatory residents lying in bed. Interviews with facility staff indicated that, to the best of their knowledge, this incident did not occur. The facility representative also denied that R1 left the facility without staff noticing. Based on the information obtained during the investigation, and despite the information on R1’s documents and the RP statement, 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 wandered away from the facility due to lack of care or supervision from staff" is deemed UNSUBSTANTIATED at this time.

Exit interview conducted/No citations issues/ A copy of report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20240823160942
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: MOM'S PLACE 3
FACILITY NUMBER: 565850347
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2025
Section Cited
HSC
1569.652(c)
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Health&Safety§1569.652(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be...resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by
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On 09/20/2024, RP emailed LPA to confirm they had received a check for the amount of twenty-four hundred dollars ($2,400) from the facility owner, covering the refund due.
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Based on interview and record review, the Licensee did not comply with the above cited section, as R1 moved out and all belongings were removed as of 07/01/2024 and a partial payment was collected by licensee on 07/01/2024 which poses a potential personal rights risk to residents in care.
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Type B
04/18/2025
Section Cited
CCR
87466
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CCR 87466 The licensee shall ensure that residents are regularly observed for changes...the licensee shall ensure that such changes are documented & ... the resident's physician and the resident's responsible person. This requirement is not met as evidenced by:
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Administrator and facility representative agreed to review regulation CCR 87466 and write a statement of understanding to ensure compliance with regulatory requirements. Administrator will submit proof to CCLD no later than POC due date.
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Based on interview and record review, the facility did not comply with the above cited section, as R1 sustained an unexplained injury on their thumb while in care, which posed a potential health risk to resident
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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: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6