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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609500
Report Date: 09/17/2024
Date Signed: 09/17/2024 03:11:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/11/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240911090516
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: 4DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Maria BangashTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff did not treat resident with respect
INVESTIGATION FINDINGS:
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On 09/17/24, at 9:25am, Licensing Program Analyst (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by caregiver Farrah Siddiqui. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint.

The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:15am, LPAs toured the physical plant. During the tour, LPA's interviewed residents and staff.

9099C-continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 5
Control Number 31-AS-20240911090516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 09/17/2024
NARRATIVE
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Regarding the allegation: Staff did not treat resident with respect. Staff are being disrespectful and aggressive to the residents. Four (4) out of five (5) residents confirmed that they are treated with respect and there has been no aggression towards them from staff. One (1) resident and two (2) staff did confirm that resident #1 (R1) was aggressive and disrespectful to resident # 2 (R2). Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time.
Exit interview conducted, signed and delivered to the Assistant Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20240911090516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 09/17/2024
NARRATIVE
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The information on this page was deleted to make a correction(s).
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5