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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610008
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:20:53 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.ASC, 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
11/26/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20241126153912
FACILITY NAME:HUMBLE HAVEN RCFE IIFACILITY NUMBER:
197610008
ADMINISTRATOR:ALAS, NICOLE DE LASFACILITY TYPE:
740
ADDRESS:37801 RUDALL AVE.TELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:6CENSUS: 5DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH: Raquel AdrianoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff speaks to resident in an inappropriate manner.
INVESTIGATION FINDINGS:
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On 12/05/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by two staff members. LPA spoke to the Administrator via phone and explained the purpose of this visit was to conduct interviews, review residents’ documents and present findings.

LPA conducted a physical plant tour at 10:00 am until 10:15 am. LPA reviewed residents’ documents at 10:30 am until 11:00 am. LPA received copies of residents' records.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 2
Control Number 31-AS-20241126153912
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
VISIT DATE: 12/05/2024
NARRATIVE
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LPA interviewed four (R1, R2, R3, R4) out of five residents at 11:00 am until 11:30 am. A resident (R5) was unavailable for an interview. LPA Spaeth interviewed three out of four staff (S1, S2, S3) at 11:30 am until 11:45 am.

Regarding the allegation: Staff speaks to a resident in an inappropriate manner. It’s being alleged a staff member is verbally abusive and yells at residents. R1 – R4 unanimously stated staff are never verbally abusive and never yells at them. R5 was unavailable for an interview. S1 – S3 also confirmed they have never verbally abused or yelled at the residents. S1 – S3 also confirmed they have never witnessed another staff member verbally abusing a resident or yelling at a resident.

Based upon resident and staff interviews, the allegation is unsubstantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2