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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609500
Report Date: 10/30/2024
Date Signed: 11/04/2024 12:58:58 PM

Substantiated


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:
10/30/2024
UNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Maria BangashTIME COMPLETED:
03:39 PM
ALLEGATION(S):
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Staff did not ensure the facility was free from mold
Staff moved residents personal property without consent
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
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 3
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: 10/30/2024
NARRATIVE
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This is the addendum of the licensing report previously issued on 09/17/24:

Regarding the allegation: Staff did not ensure the facility was free from mold. It is being alleged that there is mold coming from the air conditioner and floors. Although, four (4) out of five (5) resident interviews and one (1) staff interview determined that they have not seen any mold in any of the air conditioners or floors, LPAs were able to verify the mold that was in one (1) of the resident’s rooms behind a refrigerator. Therefore, based on the LPA's observations and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time.

Regarding the allegation: Staff moved residents’ personal property without consent. It is being alleged that the resident’s property was taken from their room and not returned to them. Although, Four (4) out of five (5) resident interviews confirmed that there was no personal property moved without their consent, LPAs were able to verify that resident # 1 (R1) did live at the above facility. The assistant administrator did state that R1 lived at the above address but did not have a file for them. LPA could not verify a file for R1 because the assistant administrator confirmed that R1 was not a resident but a person that lived there. In addition, staff # 2 (S2) did verify with the LPAs that R1 did reside at the above facility for about two (2) months. Therefore, based on the LPA's observations and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time.

Exit interview conducted, appeal rights and copy of report signed and delivered to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
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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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited
CCR
87303(a)
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(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/Licensee will need to send the removal/cleaning of the mold/mildew from behind the refrigerator and flooring in resident's room.
POC Due Date: 09/18/24
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Based on the observation and record review the licensee did not comply with the section cited above in one out of one area of mold/mildew which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
10/02/2024
Section Cited
CCR
87217(a)
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(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by
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Administrator/Licensee will reimburse resident/former resident of all personal items
POC Due Date: 10/02/24
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Based on the observation and record review the licensee did not comply with the section cited above in handling of 1 out 5 resident's property which 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: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
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