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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601489
Report Date: 01/14/2025
Date Signed: 01/14/2025 05:48:40 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
01/13/2025 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20250113114708
FACILITY NAME:CARRIE'S BOARD AND CAREFACILITY NUMBER:
197601489
ADMINISTRATOR:CARRIE ACOSTAFACILITY TYPE:
740
ADDRESS:8430 COLBATH AVENUETELEPHONE:
(818) 893-7619
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 3DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Carrie AcostaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee did not provide a copy of admissions agreement to resident as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day visit to investigate the allegation listed above. The LPA met with the Administrator Carrie Acosta and explained the reason for the visit.

The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

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

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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-20250113114708
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: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
VISIT DATE: 01/14/2025
NARRATIVE
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Licensee did not provide a copy of admissions agreement to resident as required.

It is the concern of the reporting party, that after requesting a copy of the Admission Agreement (LIC 604A) from the licensee, the licensee has failed to provide a copy to either the resident (R1) or the resident’s legal representative. To investigate the allegation, the LPA interviewed the resident (R1) and the licensee from 11:25 to 01:06 p.m. and requested records pertinent to the investigation. The interview with the R1 revealed that they had signed the LIC 604A and had requested several times from the licensee to provide them with copies of the signed agreement, however, the licensee failed to provide R1 with copies of the agreement. Furthermore, R1 stated that they asked their legal representative to request the copies from the licensee; the legal representative communicated with the licensee via email and text requesting a copy of the LIC 604A and the licensee failed to provide them with a copy as well.

The interview with the Licensee revealed that they thought they had given a copy of the LIC 604A to R1. Furthermore, the licensee stated that they probably disregarded the emails from R1’s legal representative because they did not recognize the name. Upon arrival the LPA reviewed the R1’s file and found R1’s file to have a signed and completed LIC 604A.



Based on the information obtained through interviews, the licensee did not provide a copy of admissions agreement to resident as required. Therefore, the allegation is deemed Substantiated at this time.

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

Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250113114708
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: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2025
Section Cited
HSC
1569.887(a)(c)
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1569.887 (a)(c) Signature of resident on admission agreement; copy of agreement to go to resident or resident’s representative; review. (a) The admission agreement shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative. (c) The licensee shall provide a copy of the signed and dated admission agreement to the resident or the resident's representative, if any. (d) The admission agreement shall be reviewed at the time of the compliance visit and in response to a complaint involving the admission agreement. This requirement is not met as evidenced by:
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Licensee will provide copies of the LIC604A to the resident and resident's legal representative and to the LPA by the end of the day on 01/14/2025.
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Based on information obtained, the Licensee did not comply with the above citation, as one (1) out of four (4) residents' records were not available at facility upon request for review, which poses a potential health and safety risk to residents.
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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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3