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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610008
Report Date: 03/28/2025
Date Signed: 03/28/2025 02:28:12 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.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
03/26/2025 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20250326141036
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: 6DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jasmin Bihasa, Jennifer Bihasa and Joselito Bihasa TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff did not ensure that dangerous items were inaccessible to the residents.
Facility staff did not ensure that medications were properly stored.
INVESTIGATION FINDINGS:
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On 3/28/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted an initial complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the three caregivers. LPA Spaeth spoke to the Administrator, Nicole De Las Alas at 10:45 am and explained the purpose of the visit was to tour the facility, interview the Administrator and present findings. LPA Spaeth interviewed the Administrator at 11:00 am until 11:10 am.

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

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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-20250326141036
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: 03/28/2025
NARRATIVE
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Regarding the allegation: Facility staff did not ensure that dangerous items were inaccessible to the residents. It’s alleged a knife was observed on the kitchen counter but staff were not preparing food. The Administrator confirmed a visitor had visited the facility on 3/13/2025 and observed a knife was sitting on the kitchen cabinet and the staff were not present in the kitchen when this was observed. The visitor immediately called the Administrator and expressed their concerns. The Administrator stated there had been issues with the staff and the Administrator would provide training to the staff. The Administrator confirmed with LPA Spaeth they had spoken to the visitor regarding the issue.

Regarding the allegation: Facility staff did not ensure that medications were properly stored. It’s alleged the medication cabinet was also unlocked and unattended. The Administrator confirmed the visitor also stated the medication cabinet located in the kitchen was also unlocked and staff were not present. The Administrator confirmed with LPA Spaeth they had spoken to the visitor regarding the issue.

LPA Spaeth received two photos that were taken at the facility during the incident of 3/13/2025. Upon reviewing the photo of the knife on the kitchen cabinet, LPA observed the exact location the knife was sitting on the kitchen cabinet. LPA took a photo of that location as proof the 3/13/2025 photo was the actual location of the incident. LPA reviewed the 3/13/2025 photo of the medication cabinet. LPA observed the exact location of the medication cabinet and took a photo of that location.

Based upon LPA’s observations and interview of the Administrator, the allegations are substantiated.

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

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

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
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Control Number 31-AS-20250326141036
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/01/2025
Section Cited
CCR
87309(a)
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87309 Storage Space & Access (a) Except as specified in subsection (b), the licensee shall ensure…knives, matches…are in locked storage & are not left unattended if outside the locked storage. This is evidenced by:
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The Licensee will conduct a staff
in-service training regarding the physical enviornment regulations, The Licensee will send a report stating the regulations that were reviewed and the staff's
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The staff failed to securely lock the knives and medications in a secure location. This poses an immediate health and safety risk to residents in care.
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signature when the training is completed. The documents will be sent to LPA Spaeth via email.
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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: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
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