<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221159
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:03:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2024 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20240702152855
FACILITY NAME:MAHARLIKA HOMESFACILITY NUMBER:
191221159
ADMINISTRATOR:GARDOSE, NOELLIE L.FACILITY TYPE:
740
ADDRESS:17843 CANTARA STREETTELEPHONE:
(818) 343-3936
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:4CENSUS: 4DATE:
07/09/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Monique Gardose, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure medication was not accessible to residents in care
Staff did not ensure a lid was on infectious waste garbage
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 11:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Monique Gardose, the Administrator, who granted access to the facility and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 11:45 AM, LPA requested client and staff roster. LPA requested copies of pertinent information which include, but not limited to an Approved Infection Control Plan, Medication Policy, Training, and etc. At approximately 11:50 AM, LPA conducted a physical plant tour. Between 12:00 PM – 1:00 PM, LPA interviewed the Administrator, one staff (S1), and one (1) resident out of four (4) who was available at the time of the visit.

LIC 9099-C continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
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 3
Control Number 31-AS-20240702152855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAHARLIKA HOMES
FACILITY NUMBER: 191221159
VISIT DATE: 07/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff did not ensure medication was not accessible to residents in care:
It was alleged that two prescribed medications (1) one tube of hydrocortisone and (1) one tube of Calmoseptive Ointment were accessible to residents in care. To investigate the above allegation, from 12:00 PM to 1:00 PM, LPA conducted interviews and reviewed documents pertaining to the allegation. Interviews with the Administrator and S1 confirmed that on June 11, 2024, a random unannounced visit was made by a credible witness who observed prescribed medication in the shower caddy in a resident's room accessible to resident in care. During today’s visit, LPA did not observe any prescribed/over the counter medications/vitamins left accessible to residents in care. Review of facility’s Medication Policy states that all prescribed and over-the-counter medications will be kept in a safe and locked place that is not accessible to residents in care. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED.

Staff did not ensure a lid was on infectious waste garbage:
It was alleged that a trash can inside the main resident hallway bathroom was observed without a lid by a credible witness on June 11, 2024. To investigate the above allegation, LPA interviewed Administrator and it was discovered that two weeks prior of June 11, 2024, the trash can lid was broken and did not have a tight fitting lid. During today's visit, LPA toured the facility and observed that all trash cans do have lids. However, Administrator admitted to have a trash can with infectious waste without a lid prior to LPA's visit. Based on interview and observation this allegation is deemed Substantiated at this time.

Citations issued. Appeals rights discussed and provided. Exit Interview conducted. A copy of this report provided to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20240702152855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAHARLIKA HOMES
FACILITY NUMBER: 191221159
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to schedule vendorized medication training for all staff by 08/18/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
8
9
10
11
12
13
14
Based on observation of a credible witness on 06/11/2024, the licensee did not comply with the section cited above to ensure that prescribed and PRN medication were kept locked and inaccessible to residents. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
07/16/2024
Section Cited
CCR
87303(f)(3)
1
2
3
4
5
6
7
87303 Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers…This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator purchased trash bins with lids prior to LPA visit. This POC is cleared.
8
9
10
11
12
13
14
Based on interview and observation Administrator failed to have container with tight fitting lids. This poses a potential health and safety risk or personal rights risk to residents in care.
8
9
10
11
12
13
14
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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3