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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606424
Report Date: 12/07/2022
Date Signed: 12/07/2022 03:37:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/19/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20221019133004
FACILITY NAME:HAZELWOOD MIGHTY HOMESFACILITY NUMBER:
197606424
ADMINISTRATOR:ELIZABETH A. DAGOYFACILITY TYPE:
740
ADDRESS:1557 HAZELWOOD AVENUETELEPHONE:
(323) 257-1487
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY:6CENSUS: 1DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Luzzy Dagoy, StaffTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff member is restricting access into and out of the facility.

Facility does not provide a safe environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit to deliver the findings for the above noted allegations. LPA met with Staff Luzzy Dagoy and the purpose of the visit was discussed.

It was reported that staff is restricting access into and out of the facility by having padlocks on the gates at the entrance of the facility. To investigate this allegation, on 10/26/2022 at 9:05am, LPA Valenzuela arrived at the facility and could not enter due to the gates being locked with padlocks. LPA called the facility twice and nobody answered the phone. LPA yelled and nobody came out. LPA had to jump over the fence in order to gain access to the facility. Between 9:30am and 10:30am, LPA initiated staff interviews. Interviews revealed that there are two residents currently residing at the facility. Resident #1 (R1) has walked out of the facility and wandered unto the streets. Staff said the padlocks were placed on the outside gates to keep R1 secure within the premises. LPA asked if the facility had notified Licensing and requested a fire clearance from the
See-9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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-20221019133004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424
VISIT DATE: 12/07/2022
NARRATIVE
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Fire Department. Staff said no.

Based on observation and interviews there is sufficient information to support this allegation. Therefore, this allegation is being SUBSTANTIATED at this time.

It was alleged that staff does not provide a safe environment for residents due to keeping the outdoor gates locked. To investigate this allegation on 12/07/2022 between 12:50pm and 2:05pm, LPA Valenzuela conducted a physical plant tour. LPA inspected every exit and checked to see if the alarms were working. The alarms were functional on the day of this visit. On 10/26/2022, between 9:30am and 10:30am, staff interviews were initiated. Interviews revealed that the facility put padlocks on the gates to keep the residents from wandering away from the facility. On the day that R1 left the facility, staff was busy assisting Resident #2 (R2), despite the alarms sounding off. Moreover, staff indicated that they closely supervise the residents, assist with re-directing, and make sure all knives and toxic chemicals are inaccessible. On 12/07/2022, between 2:40pm and 2:50pm, LPA initiated resident interviews. Interviews revealed that R2 feels safe and secure at the facility. On 10/26/2022, between 10:30am and 11:00am, LPA reviewed facility records. Records revealed that R1 is non-ambulatory due to a mental condition and requires close supervision due to wandering behavior.

Based on interviews, records review and observation there is sufficient information to support this allegation. Therefore, this allegation is SUBSTANTIATED at this time.

Deficiencies cited.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20221019133004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited
CCR
87468.1(a)(5)
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87468.1 Personal Rights of Residents in all Facilities-(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (5) To leave or depart the facility at any time and not be locked in any room, building, or facility premises by day or night...
This requirement was not meet as evidenced
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The Licensee shall submit to the Department a written statement by 12/14/2022 of how all residents in care will not have their personal rights violated.
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by:

The Licensee did not ensure that the personal rights of the resident were respected. R1 was not allowed to exit the facility due to padlocks being placed on the fence outside. This poses an immediate health and safety risk to residents in care.
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Type A
12/14/2022
Section Cited
CCR
87705(I)(6)
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87705 Care of Persons with Dementia-(I) The following initial and continuing requirements shall be met...(6) Locked exterior doors or perimeter fences shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents.
This requirement was not met as evidenced by:
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The Licensee shall submit to the Department by 12/14/2022 in writing how they will ensure that the facility has trained staff in sufficient numbers to meet the care and supervision needs of all residents.
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The Licensee did not ensure that trained staff in sufficient numbers was present at the facility to meet the care and supervision needs of all residents.

This poses an immediate health and safety risk to residents 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: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3