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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850601
Report Date: 01/29/2026
Date Signed: 01/29/2026 04:27:51 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
05/14/2025 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20250514101524
FACILITY NAME:SAINT LEO'S HELPING HANDSFACILITY NUMBER:
195850601
ADMINISTRATOR:NAVRUZYAN, ANIFACILITY TYPE:
740
ADDRESS:8510 SALOMA AVENUETELEPHONE:
(818) 433-1373
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 5DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Margarita SahakyanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not meeting the needs and services of the residents.
Staff provided expired medication to a resident.
Staff are unable to provide proper documentation for the residents while in care.
Unqualified staff is providing care and supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to deliver the findings for the allegations listed above. During today’s visit, LPA Urena was greeted by the staff, and the staff contacted the Administrator on the telephone. The Administrator stated they would arrive at the facility soon to meet with the LPA. The LPA met with the Administrator and explained the reason for the visit.

On 05/15/2025, Licensing Program Analyst (LPA) Sandra Urena, along with Captain Cameron Langhans from the Los Angeles City Fire Department conducted an initial 10-day visit to investigate the allegations listed above. The LPA spoke with the Administrator on the phone and explained the reason for the visit. The Administrator arrived shortly thereafter. LPA Urena interviewed the residents and Administrator from approximately 9:45 a.m. to 12:30 p.m.

Continues on LIC 9099C page 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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-20250514101524
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: SAINT LEO'S HELPING HANDS
FACILITY NUMBER: 195850601
VISIT DATE: 01/29/2026
NARRATIVE
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Page 2.
Staff are not meeting the needs and services of the residents.
On the allegation that staff are not meeting the needs and services of the residents; it is the concern of the reporting party (RP) that on 05/13/2025, R1 was found and observed to be altered and bed bound, incontinent with strong smell of urine, rapid respirations and hyperglycemia. At the time of the RP’s observation, the staff present did not speak English, was unable to locate any paperwork or information regarding the R1’s medical history, recent illnesses or baseline mental status. LPA Urena interviewed staff (S1) about the condition of R1 on 05/13/2025. The staff stated that they did not notice any urgent changes in R1 prior to leaving the facility briefly due to a personal emergency. The S1 stated that the cleaning person stayed to keep watch over the residents while the S1 was gone. However, this is when the incident occurred, and the EMT personnel arrived. The Administrator denied knowing that S1 had left the cleaning person to watch over the residents while they were gone. LPA was unable to interview the cleaning person.

Based on information obtained through interviews, the staff did not meet the needs and services of the residents when they left residents under the care of a person who did not provide care and supervision to R1 when R1 was found to be in an altered state, rapid respirations and with a strong smell of urine. Therefore, the allegation is deemed Substantiated at this time.

Staff provided expired medication to a resident.
On the allegation that staff provided expired medication to a resident; it is the concern of the reporting party (RP) that untrained staff provided EMT personnel with a box full of R1’s medication, and upon observation of the medication, EMT personnel observed an expired (03/06/2025) insulin bottle which was prescribed to R1 (a picture of the insulin bottle found at the facility was provided by credible sources). It is not clear if the staff had administered the expired insulin to the R1. To investigate the allegation, the LPA requested a copy of the LIC 622 (Centrally Stored Medication and Destruction Record). The LIC 622 was observed to have outdated entries at the time of the visit, with the last entries made as ‘medication received on 03/10/2025’. No record of the insulin was found on the LIC 622. No medication was available to review on the day of the visit.

Continues on LIC 9099C...page 3.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250514101524
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: SAINT LEO'S HELPING HANDS
FACILITY NUMBER: 195850601
VISIT DATE: 01/29/2026
NARRATIVE
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Page 3.
Based on the record review in addition to the RP’s report, credible witnesses and pictures, the preponderance of the evidence supports that the staff provided expired medication to a resident. Therefore, the allegation is deemed Substantiated at this time.

Staff are unable to provide proper documentation for the residents while in care.
On the allegation that staff are unable to provide proper documentation for the residents while in care; it is the concern of the RP that staff were unable to provide EMT personnel with the resident’s medical information at the time they arrived to transport R1 to the hospital. To investigate the allegation, LPA Urena conducted an initial visit on 05/15/2025; at this time the LPA requested records pertaining to R1 pertinent to the investigation and interviewed the staff, administrator and residents. The Administrator’s interview revealed that they were not sure why the staff did not provide the R1’s medical records. The Administrator provided to the LPA the following records: LIC 602 (Physician’s Report dated 03/21/2025) and LIC 622 (Centrally Stored Medication and Destruction Record). The LIC 622 was outdated at the time of the visit. The interview with staff revealed that at the time of the EMTs arrival they had stepped out of the facility to attend to a family emergency, consequently they left the cleaning person at the facility for a short period, and the cleaning person did not have access to the residents’ records.

Based on the information obtained through credible sources, and interviews with staff, the staff present at the time of the incident were unable to provide proper medical information for the residents while in care. Therefore, the allegation is deemed Substantiated at this time.

Continues on LIC 9099C... page 4
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20250514101524
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: SAINT LEO'S HELPING HANDS
FACILITY NUMBER: 195850601
VISIT DATE: 01/29/2026
NARRATIVE
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Page 4.
Unqualified staff is providing care and supervision.
On the allegation that unqualified staff is providing care and supervision; it is the concern of the RP that staff present at the facility on the day of the incident were not qualified to provide care and supervision to the residents in care. To investigate the allegation, the LPA interviewed the staff and Administrator. The Administrator denied knowing that staff (S1) left the cleaning person to watch over the residents while S1 attended to a personal emergency. S1 confirmed that they left briefly, and left cleaning person at the facility. S1 claimed they were gone for maybe 15 minutes and when they came back the EMTs had taken the R1 to the hospital. The LPA confirmed via Personnel Report that cleaning person was not associated with the facility at the time of the incident.

Based on information obtained via Personnel Report and interviews, unqualified staff were present providing care and supervision to residents in care. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.




SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20250514101524
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: SAINT LEO'S HELPING HANDS
FACILITY NUMBER: 195850601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2026
Section Cited
CCR
87411(a)(c)(g)-(1-3)
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 Personnel Requirements – General (a) Facility personnel shall at all times be
…competent to provide the services necessary to meet resident needs… (c) All RCFE staff who assist residents with
Personal activities of daily living shall receive initial and annual training as specified in… (g) Prior to employment or
Initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1)Obtain a California clearance or a criminal record exemption as required by law or Department regulations or…
This requirement is not met as evidenced by:


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POC: Administrator stated that they will review regulations as they pertain to Personnel Requirements and will submit Letter to LPA as self certification.
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Based on observation: The licensee did not comply with the section cited above as one person left to care for residents was not competent or qualified to provide the services necessary, which poses an immediate health and safety risk to persons in care.
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Type A
02/09/2026
Section Cited
CCR
87465(a)(4)(e)(1-4)
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(a)(4)(e)(1-4) The licensee shall assist residents with self-administered medications as needed. (e) For every
prescription…medication for which the licensee provides assistance there shall be a signed, dated written
order from a physician…maintained in the residents file, and a label on the medication…This requirement is not me
as evidenced by:
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As of today's visit the Administrator provided proof of training for current working staff.

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Based on observation and record review, the licensee did not comply with the section cited above as 1 of 6 residents medication reviewed was expired at the time of the visit and not reflected in the LIC 622, which poses an immediate health and safety risk to persons 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: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20250514101524
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: SAINT LEO'S HELPING HANDS
FACILITY NUMBER: 195850601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2026
Section Cited
CCR
87355(e)(2)
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 87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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POC: Cleaning person was no longer at the facility. Administrator understood that individuals cannot be present without clearance.
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 Based on interview and record review, the licensee did not comply with the section cited above when an uncleared individual was left with residents, which poses an immediate health and safety risk to persons in care.
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Type B
02/09/2026
Section Cited
CCR
87506(a)(b)(1-16)
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87506(a)(b)(1-16) Resident Records-The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (b) Each resident’s record shall contain at least the following information… This requirement is not met as evidenced by:
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POC: Administrator stated that they will review regulations as they pertain residents' records and will submit letter to LPA as self-certification.
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Based on observation and record review, the licensee did not comply with the section cited above as 1 of 6 residents records were not available for reviewed for EMT personnel and a full file for the department which included an expired LIC 622, which poses a potential health and safety risk to persons 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: Jill Nakata
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6