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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609500
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:27:02 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: 5DATE:
03/24/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Farah BangashTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Uncleared adults in the home.
Facility has expired foods.
Facility does not follow safe food handling practices.
Administrator is not present at the facility a sufficient amount of time.
INVESTIGATION FINDINGS:
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At 9:30 a.m. Licensing Program Analysts (LPAs) Melissa Ruiz and Angela Panushkina arrived at the facility to conduct an unannounced subsequent complaint investigation. Upon arrival, LPAs were greeted by the Administrator Farah Bangash and designee Maria Bangash. An entrance interview was conducted, and LPAs explained the purpose of the visit.

Allegation – Uncleared adults in the home.

It was alleged that there is or was uncleared adults in the home. On a visit conducted by Ombudsman on 3/10/22, Ombudsman witnessed a female individual enter the home from the backyard and pick up grocery bags that were delivered to the facility address. LPA interviewed designee Maria and based on the interview; it was revealed that the female individual was a guest residing in the Airbnb rental located in the backyard. Additionally, designee Maria stated the outdoor laundry room was shared between facility residents and staff and Airbnb guests. (cont. on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
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 4
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: 03/24/2022
NARRATIVE
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Based on Ombudsman observation and an interview conducted with the designee, this allegation is substantiated. On a visit conducted by LPA Shanahan on 3/10/22, a deficiency and civil penalty was issued regarding this allegation. A plan of correction of was issued as well. On today’s visit, LPA Ruiz asked for a written statement/agreement that Airbnb guests will not under any circumstances enter or use the facility premises.

Allegation - Facility has expired foods.
Allegation - Facility does not follow safe food handling practices.

It was alleged that facility has expired foods. On a visit conducted by Ombudsman on 3/10/222, Ombudsman observed eggs in the refrigerator that had a “sell by” date of 2/17/22. Ombudsman also observed a container of rice in the refrigerator without a proper lid. Additionally, LPA Martinez issued an annual report on 3/16/22 stating “Food storage and preparation areas were dirty and need immediate cleaning. All three (3) refrigerators in the facility were observed to have food stains, crumbs, and old liquid spills from frozen meats.” Based on Ombudsman observation and LPA observation, these two (2) allegations are substantiated.

Allegation - Administrator is not present at the facility a sufficient amount of time.

It was alleged that the Administrator is not present at the facility. On 3/10/22 Ombudsman conducted a visit and neither the Administrator nor the designee were available at the time. On a visit conducted by LPA Ruiz and LPA Martinez on 3/16/22, LPAs met with designee Maria and were informed that the Administrator was “out of town”. On that day, LPAs checked records, and no notification was submitted to the Regional Office (RO) regarding the Administrator’s absence. On today’s visit, LPAs Ruiz and Panushkina were informed by the Administrator that she had returned to the country yesterday, 3/24/22. Administrator stated she forgot to notify our RO of her absence from 2/24/22 to 3/23/22. LPAs had a verbal conversation reminding the Administrator to notify the RO of planned or unforeseen absences. Based on observation, document review and interviews, 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: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2022
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...

This requirement is not met as evidenced by:
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LPAs obtained copy of updated LIC500 which was submitted to assigned LPA on 3/20/22. LIC500 reflects updated Administrator hours.
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Based on document review & observation, the Administrator didn’t comply with section cited above. On three separate visits, the Administrator was not present a sufficient number of hours to permit adequate attention to the management and administration of the facility resulting in multiple deficiencies & compliance issues. This an poses an immediate health and safety risk to residents in care.
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Type A
CCR
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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: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2022
Section Cited
CCR
87555(b)(28)
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87555(b)(28) General Food Service Requirements All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.
This requirement is not met as evidenced by:
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Based on LPAs observation, this deficiency has been cleared as of today's visit.
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Based on food inspection conducted by Ombudsman on 3/10/22 it was observed that the facility kept expired eggs and rice without an appropriate cover in the refrigerator. Moreover on 3/16/22, LPAs observed 3 refrigerators with crumbs, stains and liquid spills from frozen meat. This poses a potential health and safety risk to the 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: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4