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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609500
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:22:27 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
03/15/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220315122504
FACILITY NAME:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR:BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 6DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria BangashTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility is overcapacity.
Facility does not have sufficient staff to meet residents' needs
Resident's records are not complete and/or missing.
Resident's records are not adequately stored.
Medications are not locked at the facility.
Facility does not provide a safe and hazard free environment for residents.
Facility is in disrepair.
Residents have access to dangerous items.
INVESTIGATION FINDINGS:
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At 9:30 a.m. Licensing Program Analysts (LPA’s) Joscelyn Martinez, Melissa Ruiz and Ombudsmen Velvet Tabby arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPA’s and Ombudsmen was greeted by Maria Bangash. Maria stated she was the current Administrator designee, as the Administrator was out of town. An entrance interview was conducted, and LPAs explained the purpose of the visit.

Allegation #1 - Facility is overcapacity.

It was alleged that the facility is or was . On an annual inspection conducted on 3/10/2022 by LPA Shanahan observed that there were seven (7) residents present at the facility. During today’s visit, LPA interviewed the designee Maria, who also confirmed that they did in fact have seven (7) residents in care at one point. The facility license had been approved for a maximum capacity of six (6) residents. Based on previous LPA observation and an interview, this allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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 8
Control Number 31-AS-20220315122504
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: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 03/16/2022
NARRATIVE
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Allegation #2 - Facility does not have sufficient staff to meet residents' needs.

Upon arrival, designee Maria told LPA’s that she is currently the only staff providing care and supervision to all six (6) residents in care. She stated that another staff member would be back later today, as staff was at the hospital. LPAs were able to obtain staff’s phone number and staff member told LPA’s that they resigned and will no longer be coming back to the facility. Based on LPA’s observation and an interview conducted, this allegation is substantiated.

Allegation #3 - Resident's records are not complete and/or missing.
Allegation #4 - Resident's records are not adequately stored.

At 9:45 a.m., LPAs began touring the facility. Upon touring the second floor of the home, residents’ records were observed to be stacked in a small bookshelf in a staff bedroom along with other personal belongings. LPAs observed five (5) resident records, four (4) of which pertained to residents who currently reside at the facility. LPAs asked the designee Maria for the records of the two (2) additional residents. Maria was unable to provide the records and stated the Administrator Farah has the knowledge of the whereabouts of the two (2) resident records. Based on LPAs observation and interview, these two allegations are substantiated.

Allegation #5 - Medications are not locked at the facility.



Upon touring the kitchen, LPAs observed two (2) medication storage bins accessible to residents in one of the kitchen cabinets. LPAs instructed the designee Maria to immediately lock the medications in the designated storage cabinet. Based on LPAs observation, this allegation is substantiated.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 31-AS-20220315122504
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: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 03/16/2022
NARRATIVE
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Allegation #6 - Facility does not provide a safe and hazard free environment for residents.
Allegation #7 - Facility is in disrepair.

During the rest of the facility tour, LPAs observed a smoke alarm detector pulled out with no batteries and wires hanging out. LPAs observed a staff bedroom door to be broken and wood sticking out of the bottom of the door which could be dangerous to staff and residents. LPAs observed two (2) windows - one in the kitchen and one in the bathroom to be missing a screen. A kitchen cabinet door was broken, and it was placed off to the side. Based on the observations mentioned above, these allegations are substantiated.

Allegation #8 - Residents have access to dangerous items.

When LPAs continued the tour in the backyard, LPAs observed two (2) large pickaxes on the side of the facility. In the designated detached laundry room, there was various tools intended for construction or repairs. Based on LPAs observations this allegation is substantiated.



Deficiencies were issued per CA code of Regulations Title 22. See 9099D's included with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 31-AS-20220315122504
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: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2022
Section Cited
CCR
87204(a)
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87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license including the maximum number of persons who may receive services at any one time.

This requirement is not met as evidenced by:
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There are now only six (6) residents in care. Plan of correction has been cleared as of today's visit, 3/16/2022. .
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Based on LPAs observation on an annual visit on 3/10/22, the licensee did not comply with the section cited above as 7 residents were living at this facility which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
03/18/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
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The Administrator shall initiate the process to hire additional staff. Proof of hiring additional staff and updated LIC500 shall be submitted to LPA Martinez via e-mail by 3/18/2022.
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Based on LPA observation and interviews, the licensee failed to provide sufficient staff for residents in care. There was one (1) staff member for six (6) 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 31-AS-20220315122504
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: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2022
Section Cited
CCR
87705(f)(1)(2)
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87705 (f)(1)(2) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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Administrator shall ensure that medications, tools, cleaning supplies and other dangerous items shall remain locked and inaccessible to clients in care. Administrator shall conduct in house training with all staff and copies and photos shall be submitted to LPA Martinez by 3/20/22.
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Based on LPAs observations, the Administrator did not ensure that medications, tools, and cleaning supplies were inaccesible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care due to dementia 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 31-AS-20220315122504
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: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2022
Section Cited
CCR
87506(a)
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87506 Resident Records a) 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.

This requirement is not met as evidenced by:
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The Administrator will provide proof of resident files/records for 2 out of the 6 residents. Administrator is to email proof of records/documents to LPA by 3/20/2022.
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Based on observation, interview and record review, the Administrator failed to provide two (2) out of sixe (6) resident records. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/20/2022
Section Cited
CCR
87506(c)(1)
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78506(c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

This requirement is not met as evidenced by:
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The Administrator is to desginate a confidential space for record keeping such as a locked storage cabinet for confidential record keeping. Proof will be submitted to LPA by 3/20/2022.
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Based on observation, the Administrator did not ensure that resident records remain confidential as they were located in a shared bookshelf in one of the bedrooms. This poses a potential health, safety or personal rights 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 31-AS-20220315122504
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: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Administrator is to hire a outside company or a weekly housekeeper. Administrator will send documentation proof that indicates they have hired housekeeping services.
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Based on LPA observation during the annual conducted concurrently today, bathrooms were observed to be unsanitary, one bedroom had a strong urine smell, and the refrigerators were contaminated with old food spills including old packaged meat liquids.This poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/20/2022
Section Cited
CCR
87307(d)(2)
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87307 Personal Accommodations and Services (d) (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
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Administrator is to hire a repair company to come and fix/repair items mentioned in today'a annual and complaint report. Photo proof of repair or intent to repair will be submitted by the POC date.
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Based on LPA observation during the annual conducted concurrently today, two window screens are in disrepair, facility has large cracks in walls, kitchen cabinets are in disrepair, one fire alarm detector is in disrepair, staff bedroom door is broken, staff bedroom wall has a hole, and outlet covers are missing and have exposed wires in one of the bedrooms. This poses a potential health, safety or personal rights 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8