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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850534
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:42:08 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
03/04/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250304101019
FACILITY NAME:COMPLETE HARMONY BOARD AND CARE INCFACILITY NUMBER:
195850534
ADMINISTRATOR:MARTINYAN,NURITSAFACILITY TYPE:
740
ADDRESS:14912 GILMORE STTELEPHONE:
(818) 425-2317
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:6CENSUS: 5DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH: Nurista MartinyanTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility did not provide adequate care and supervision to a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 02:22 PM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 02:28 PM. Entrance interview conducted and the reason for the visit was explained.

During the initial complaint visit on 03/07/2025 LPA conducted a physical plant tour ,conducted a file review for five (5) residents, conducted a medication review for one (1) resident, interviewed the Administrator, one (1) staff member, and four (4) residents between 09:56 AM and 12:20 PM. During today’s visit between 02:25 PM and 03:15 PM LPA conducted a brief physical plant tour and interviewed one (1) staff member.

Continued on LIC-9099C
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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 3
Control Number 29-AS-20250304101019
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: COMPLETE HARMONY BOARD AND CARE INC
FACILITY NUMBER: 195850534
VISIT DATE: 03/12/2025
NARRATIVE
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The allegation of “Facility did not provide adequate care and supervision to a resident” alleges that the facility did not provide an adequate level of supervision for resident #1 (R1) which resulted in the elopement of R1 from the facility. LPA Byrne interviewed the Administrator who informed LPA that R1 eloped from the facility’s grounds on 03/01/2025. The Administrator stated that R1 left the facility when Staff #1 (S1) was busy assisting with the care of another resident of the facility. The Administrator stated that after it was observed that R1 had left the facility, they and other facility staff searched the areas around the facility for R1. LPA confirmed with the Administrator that R1 was found by the local police department and has been placed in the hospital awaiting discharge. LPA interviewed S1 who was working at the time of R1’s elopement from the facility. S1 stated that R1 eloped during breakfast time. S1 stated that R1 left from the front door of the facility while they were assisting another resident. S1 stated that they turned the front door’s auditory alarm off in the morning, but they had the front door closed. During the physical plant tour LPA observed the front door of the facility to be equipped with a functioning auditory alarm. However, the alarm was observed to be switched off due to the front door being propped open. Based on the information obtained during interviews and physical plant tour there is sufficient evidence to support the allegation of “Facility did not provide adequate care and supervision to a resident.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250304101019
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: COMPLETE HARMONY BOARD AND CARE INC
FACILITY NUMBER: 195850534
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Licensee will submit their plan on how they will ensure adequate staff supervision of clients to CCLD no later than POC due date.
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Based on interview the licensee did not comply with the section cited above as R1 eloped from the facility without staff's knowledge which poses a potential safety rick to clients 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3