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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610011
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:25:59 PM

Substantiated


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
07/08/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240708173002
FACILITY NAME:MASCHELLE VILLAFACILITY NUMBER:
197610011
ADMINISTRATOR:LEBORA D NAKAHARAFACILITY TYPE:
740
ADDRESS:25577 ALMENDRA DRIVETELEPHONE:
(661) 425-7500
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 3DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Micaela Baliwag TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Unfingerprinted staff are providing care and supervision to residents.
Staff are not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Micaela Baliwag and explained the reason for the visit.

---Unfingerprinted staff are providing care and supervision to residents.

It was alleged that Staff #3 (S3) worked at the facility without a fingerprint clearance. To investigate the allegation, on 07/17/2024 LPA requested pertinent documents at 11:00 AM and interviewed one (01) staff from 11:00 AM to 11:45 AM. A review of the facility’s records revealed that Staff #3 (S3) was not fingerprint cleared. During interviews with staff, Staff #1 (S1) stated S3 was only employed for one week and replaced two former staff when they abruptly departed.

(CONT. on LIC9099- C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
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 7
Control Number 31-AS-20240708173002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MASCHELLE VILLA
FACILITY NUMBER: 197610011
VISIT DATE: 10/10/2024
NARRATIVE
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Based on record review and interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

---Staff are not adequately trained

It was alleged that staff are not adequately trained and do not have training documents in their personnel file. To investigate the allegation, on 07/17/2024 LPA requested pertinent documents at 11:00 AM and interviewed one (01) staff from 11:00 AM to 11:45 AM. A review of the facility’s files revealed that Staff #2 (S2), S3 and S4 did not have the required training documentation on file to provide the necessary care and supervision.

Based on record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 31-AS-20240708173002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MASCHELLE VILLA
FACILITY NUMBER: 197610011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
CCR
87355(d)(e)(1)
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87355 Criminal Record Clearance (d) All individuals..shall be fingerprinted and sign a Criminal Record Statement..(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b)shall prior to working,.. in a licensed facility: (1) Obtain a
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Administrator will submit a written letter by the POC due date stating that they will review Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87355 Criminal Record Clearance and that going forward will adhere to these regulations.
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California clearance or a criminalrecord exemption..This requirement is not met as evidenced by; Based on record review, the facility did not ensure that staff working in the facility have fingerprint clearance. This poses a potential health, safety and personal rights risk to residents in care.
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Type B
10/14/2024
Section Cited
CCR
87412(a)(13)(A)(d)
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87412 Personnel Records(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee…(13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (A) A signed statement regarding their
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Administrator will submit a written letter by the POC due date stating that they will review Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87412 Personnel Records and that going forward will adhere to these regulations.
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criminal record history as required by Section 87355(d). This requirement is not met as evidenced by; Based on record review, the facility did not ensure that staff working in the facility have fingerprint clearance. This poses a potential health, safety and personal rights risk to residents 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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20240708173002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MASCHELLE VILLA
FACILITY NUMBER: 197610011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
CCR
87412(a)(13)(d)(4)
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87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on.. each employee..(13) (c)Licensees shall maintain.. verification of required staff training and orientation.(d).. training and/or related experience shall provide..(4) Knowledge required to safely
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Administrator will submit a written letter by the POC due date stating that they will review Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87412 Personnel Records and that going forward will adhere to these regulations.
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assist with prescribed medications..This requirement is not met as evidenced by; Based on record review, the facility did not ensure that staff working in the facility have the required training to provide the necessary care and supervision to residents. This poses a potential health, safety and personal rights risk to residents 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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
07/08/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240708173002

FACILITY NAME:MASCHELLE VILLAFACILITY NUMBER:
197610011
ADMINISTRATOR:LEBORA D NAKAHARAFACILITY TYPE:
740
ADDRESS:25577 ALMENDRA DRIVETELEPHONE:
(661) 425-7500
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 3DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Micaela Baliwag TIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff conduct poses a risk to residents in care.
Staff are not providing adequate food service.
Staff do not keep the facility free from pest.
Staff do not ensure that hazardous items are inaccessible to residents.
Staff are mismanaging resident medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Micaela Baliwag and explained the reason for the visit.

---Staff conduct poses a risk to residents in care.

It was alleged that smoked meth and vaped in the facility. To investigate the allegation, on 07/17/2024 LPA conducted physical plant tour at around 10:15 AM and interviewed one (01) staff from 11:00 AM to 11:45 AM. On 10/10/2024, LPA interviewed one (01) additional staff and one (01) out of three (03) residents from 12:00 PM to 01:00 PM. LPA was unable to interview other residents due to conditions. During the physical plant tour LPA did not observe any drugs or drug paraphernalia and did not experience any malodor. During interviews with staff all staff stated they are not aware of any staff smoking or vaping in the facility.
(CONT. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 31-AS-20240708173002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MASCHELLE VILLA
FACILITY NUMBER: 197610011
VISIT DATE: 10/10/2024
NARRATIVE
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During interviews with resident, Resident #1 (R1) stated they are unaware of any drug use in the facility.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation in UNSUBSTANTIATED at this time.

---Staff are not providing adequate food service.

It was alleged that the food in the facility is kept passed the expiration dates. To investigate the allegation, on 07/17/2024 LPA conducted physical plant tour at around 10:15 AM and interviewed one (01) staff from 11:00 AM to 11:45 AM. On 10/10/2024, LPA interviewed one (01) additional staff and one (01) out of three (03) residents from 12:00 PM to 01:00 PM. LPA was unable to interview other residents due to conditions. During the physical plant tour LPA did not observe any expired foods. During interviews with staff, all staff stated they are unaware of any expired foods being kept or served in the facility. During interviews with resident, R1 stated they are not aware of facility storing or serving expired foods.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation in UNSUBSTANTIATED at this time.

---Staff do not keep the facility free from pest

It was alleged that the facility has pest (roaches) in the kitchen. To investigate the allegation, on 07/17/2024 LPA conducted physical plant tour at around 10:15 AM and interviewed one (01) staff from 11:00 AM to 11:45 AM. On 10/10/2024, LPA interviewed one (01) additional staff and one (01) out of three (03) residents from 12:00 PM to 01:00 PM. LPA was unable to interview other residents due to conditions. During the physical plant tour, LPA did not observe any roaches or pests in the facility. During interviews with staff, all staff stated they have not witnessed any roaches or pests in the facility. During interviews with resident, R1 stated they have not witnessed any roaches in the facility.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation in UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 31-AS-20240708173002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MASCHELLE VILLA
FACILITY NUMBER: 197610011
VISIT DATE: 10/10/2024
NARRATIVE
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---Staff do not ensure that hazardous items are inaccessible to residents

It was alleged that there are hazards such as chemicals and medicated ointments accessible in the resident's bedrooms behind the sliding cabinets. To investigate the allegation, on 07/17/2024 LPA conducted physical plant tour at around 10:15 AM, requested pertinent documents at 11:00 AM and interviewed one (01) staff from 11:00 AM to 11:45 AM. On 10/10/2024, LPA interviewed one (01) additional staff and one (01) out of three (03) residents from 12:00 PM to 01:00 PM. LPA was unable to interview other residents due to conditions. During the physical plant tour, LPA did not observe any unlocked chemicals or toxins accessible to residents. During interviews with staff, all staff stated that all toxins and chemicals are kept locked and inaccessible to residents. During interviews with resident, R1 stated they are unaware of unlocked or accessible toxins and chemicals.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation in UNSUBSTANTIATED at this time.

---Staff are mismanaging resident medication

It was alleged that the current caregivers may not have adequate training as evidenced by certificates or records to administer medications. To investigate the allegation, on 07/17/2024, LPA requested pertinent documents at 11:00 AM and interviewed one (01) staff from 11:00 AM to 11:45 AM. A review of the facility’s files revealed that Staff #2 (S2), S3 and S4 did not have the required training documentation on file to provide the necessary care and supervision. Although the aforementioned staff do not have training documents on file, other staff in the facility that are responsible for medication distribution have the required training. A review of the Medication Administration Records also shows that all medications were distributed as prescribed.

Based on record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No other health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7