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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606784
Report Date: 01/29/2024
Date Signed: 01/30/2025 03:17:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
01/23/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20240123154443
FACILITY NAME:HERITAGE OF NORTHRIDGEFACILITY NUMBER:
197606784
ADMINISTRATOR:MIJARES, MARYANNFACILITY TYPE:
740
ADDRESS:19251 CALAHAN STREETTELEPHONE:
(818) 775-9806
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 4DATE:
01/29/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Mary Ann Mijares- AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Due to lack of supervision, attempted physical assault on resident by an unknown person
INVESTIGATION FINDINGS:
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This is an amended report of the prior investigation report delivered on 01/29/24. The amended report includes additional information regarding the investigation. The determination of the allegation remains Unsubstantiated. Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced complaint visit to investigate the above stated allegation. LPA was greeted by S1. Shortly after the Administrator arrived at the facility and explained the reason for the visit. At 9:30 am, LPA requested resident and staff roster. At approximately 09:45 am, LPA conducted a physical plant tour, to ensure health and safety of the residents.

Allegation: Due to lack of supervision, attempted physical assault on resident by an unknown person
It was alleged that on 1/18/2024 a male attempted to physically assault R1. At 10:15 Am today, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s report, Appraisal Needs and Services Plan, Staff Schedule, etc., relevant to the investigation. Between 11:00am – 12:10 PM, LPA interviewed Administrator and one (1) out of 2 staff members and four (4) out of four (4) residents. (Continue LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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 2
Control Number 31-AS-20240123154443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HERITAGE OF NORTHRIDGE
FACILITY NUMBER: 197606784
VISIT DATE: 01/29/2024
NARRATIVE
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The administrator denied the allegation. Interview with the Administrator revealed that there was only a female caregiver on the night shift of 1/18/2024. Administrator indicated that R1 has a history of hallucinations, predominately at night. Information obtained during interviews with 2 out of 4 residents did not corroborate the allegation. Interview with S1 revealed that R1 hallucinates every time R1 is alone in the room even in the daytime. Per S1 there were no visitors in the facility on 1/18/24. During the visit, LPA conducted an interview with R1. Immediately after the interview was concluded, LPA witnessed R1 having an apparent hallucination of being physically assaulted while R1 was alone in R1’s room. Information obtained during an interview with R1’s former conservator (W1) indicated that R1 has a history of hallucinations, similar to the allegation. W1 advised that W1 visits R1 weekly and has observed that R1 is well cared for, and R1’s physical appearance and health appear to have improved during R1’s residence at the facility. W1 also indicated that R1’s Family Member (W2) was an unreliable source of information for the purpose of this investigation. Based on interviews and record reviews there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.







SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2