197609500-1-14-2025-31-AS-TAGD-DDBU2V-20250127141233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609500
Report Date: 01/14/2025
Date Signed: 01/14/2025 12:47:15 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
01/07/2025 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250107085344

FACILITY NAME:	DEVONSHIRE ELDERLY CARE		FACILITY NUMBER:	197609500
ADMINISTRATOR:	BANGASH, FARAH		FACILITY TYPE:	740
ADDRESS:	17441 DEVONSHIRE STREET		TELEPHONE:	(310) 955-0674
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 4	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Farah Siddiqui, Caregiver		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Staff are verbally abusing a resident while in care
Staff are mistreating resident while in care

INVESTIGATION FINDINGS:

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On 01/14/25, at 8:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Farah Siddiqui, Caregiver. 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 9:25am, LPA toured the physical plant. During the tour, LPA interviewed residents and staff.

9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250107085344

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: 01/14/2025

NARRATIVE

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Regarding the allegation: Staff are verbally abusing a resident while in care. It is being alleged that the staff yell and are rude to resident #1 (R1). LPA interviewed three (3) staff that reported R1 is aggressive. Staff #1 (S1) reported that R1 tried to hit them while telling them not to be aggressive to one (1) of the residents. Staff #2 (S2) reported that R1 was always arguing with resident #3 (R3). Staff #3 (S3) reported that R1 had recently moved in but when they did not have the full attention of the staff they would start yelling and try to become aggressive to the other residents. LPA interviewed four (4) residents that confirmed staff have not verbally abused them, yelled at them or ever been rude to them. Resident #3 (R3) reported that R1 would yell at them and threw a cup at them. Furthermore, LPA obtained the Unusual Incident/Injury Report of R1 being aggressive on 01/02/25. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff are mistreating resident while in care. It is being alleged that while resident #1 (R1) is being changed they toss a blanket on them. LPA interviewed three (3) staff that confirmed they have never mistreated their residents while in care. LPA interviewed four (4) residents that confirmed they have never been mistreated while in care and/or staff have never tossed a blanket or any type of clothing on them while they are being changed. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time.

Exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Assistant Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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