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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606737
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:13:47 PM

Unsubstantiated


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 Joscelyn Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221019120003
FACILITY NAME:A HEAVENLY HAVEN, INC. IIFACILITY NUMBER:
197606737
ADMINISTRATOR:FRANCISCA RECEDEFACILITY TYPE:
740
ADDRESS:20000 LASSEN STREETTELEPHONE:
(818) 775-9397
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 5DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Francisca RecedeTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff yell at residents
Staff withhold water from residents
Staff handle residents in a rough manner
Staff force feed residents
Staff did not seek medical attention based on observed change of condition
Staff do not properly maintain records of centrally stored medication
INVESTIGATION FINDINGS:
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On 11/08/22 Licesning Program Analsyt (LPA) Joscelyn Martinez arrvied at the facility to conduct a subsequent complaint visit .Upon arrival LPA was met by Administrator Francisca Recede and the purpose of the visit was explained. Initial visit was conducted on 10/26/22.

Allegation: Staff yell at residents
Allegation: Staff withhold water from residents
Allegation: Staff handle residents in a rough manner
Allegation: Staff force feed residents
Allegation: Staff did not seek medical attention based on observed change of condition

It is alleged that staff have yelled at the residents, withheld water, forced fed, handled residents in a rough manner and that staff did not seek medical care in for a resident's change of condition. To investigate these allegations, LPA conducted interviews with three staff and one resident .
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
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 2
Control Number 31-AS-20221019120003
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: A HEAVENLY HAVEN, INC. II
FACILITY NUMBER: 197606737
VISIT DATE: 11/08/2022
NARRATIVE
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Interviews with three (3) out of three (3) staff revealed that there has never been in a time in where staff have yelled at residents, withheld water, handled residents in a rough manger, force fed residents or failed to provide medical attention to residents. Staff stated they have not witness another staff doing any of these allegations. LPA attempted to interview all five (5) residents. Due to resident's medical condition only one (1) resident was able to provide answers to the interview. Interview with resident (R1) stated they have never been a victim of the allegations mentioned above. R1 also stated they have not witness staff yell at residents, withhold water from residents, treat resident in a rough manner, force fed residents, or failed to provide medical attention. R1 stated all of the staff goes above and beyond for everyone and the administrator is very active in the facility. R1 stated residents are treated with respect and are taken care of very well by staff. Based on interviews these allegations are deemed Unsubstantiated at this time.

Allegation: Staff do not properly maintain records of centrally stored medication

It is alleged that facility does not properly maintain records of centrally stored medication. To investigate this allegation, LPA collected all five (5) residents' Centrally Stored Medication and Destruction Records (LIC 622). Document review revealed that facility is properly maintain records of resident's centrally stored medication. Interviews with three (3) out of three (3) staff revealed facility does maintain an updated LIC 622. Interview with administrator stated every time medication is delivered or picked up, LIC 622 is updated for the resident. Based on document review and interviews, this allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2