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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609731
Report Date: 10/05/2021
Date Signed: 10/05/2021 01:36:04 PM

Unsubstantiated


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
08/07/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200807114542
FACILITY NAME:G & A CAREFACILITY NUMBER:
197609731
ADMINISTRATOR:KOSOYAN, GRIGORFACILITY TYPE:
740
ADDRESS:16301 NORDHOFF STREETTELEPHONE:
(323) 314-2996
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 4DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Grigor KosoyanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yelled at resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegation.
During this investigation LPA conducted a virtual visit on 8/13/20 and interviewed the administrator and 3/5 residents; conducted an in-person visit on 10/5/21 and interviewed the administrator, 4/4 residents, and attempted to interview Resident 1 (R1) and their responsible party.

Allegation #1, that “Staff yelled at resident,” has been unsubstantiated based on the interviews conducted. No corroborating evidence was provided by the complainant, none of the interviews conducted on 8/13/20 or 10/5/21 corroborated the allegation. LPA was unable to obtain any other evidence or testimony to substantiate the allegation.

Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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