197610327-8-29-2025-31-AS-NMAN-DLYQMX-20250929121817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610327
Report Date: 08/29/2025
Date Signed: 08/29/2025 01:54:35 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
11/21/2024 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20241121154006

FACILITY NAME:	HAVEN HOMES		FACILITY NUMBER:	197610327
ADMINISTRATOR:	HOROWITZ, JESSICA		FACILITY TYPE:	740
ADDRESS:	10507 ANDASOL AVE		TELEPHONE:	(818) 324-7536
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 3	DATE:	08/29/2025
		UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	Aniyah Williams		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Questionable Death.
Staff did not respond to resident's requests for assistance in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. LPA met with staff, Aniyah Williams, and advised her of the complaint. During the course of this investigation, interviews with the administrator, staff and residents were made. LPA conducted a physical plant inspection of the facility to insure the health and safety of the residents. LPA also obtained medical records pertaining to the above allegations.

Questionable Death:
In regards to the allegation, it was reported that Resident 1 (R1) experienced a fall on or around August 27, 2024. R1 was transported to the hospital and admitted for observation on the same day. R1 was diagnosed with a subdural hematoma. On or around August 30, 2024, R1 was discharged to return to the facility. On or around September 5, 2024, R1 was found unresponsive. R1 was sent back to the hospital, and passed away on September 9, 2024. It’s being alleged that R1’s fall, which resulted to the subdural hematoma

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Angela J Whittaker
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

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-20241121154006

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: HAVEN HOMES	FACILITY NUMBER: 197610327
	VISIT DATE: 08/29/2025

NARRATIVE

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caused or contributed to R1’s death.

Interview with facility administrator confirms that R1 had a fall, resulting in subdural hematoma on or around August 27, 2024. The administrator also confirms that R1 was found unresponsive on or around September 5, 2024, and passed away on September 9, 2024. The administrator denies that R1’s fall, leading to the subdural hematoma, contributed to R1’s death. The administrator stated R1’s current diagnoses and condition contributed to the cause of death.

Review of R1’s records indicate that R1 was already taking medications to prevent heart attack and stroke. R1’s physical health status when admitted on January 27, 2023, was marked fair by the physician. Per death certificate, cause of death was stroke and hypertension.

On April 21, 2025, LPA Cava requested for a Program Clinical Consultant (PCC) review to confirm if the subdural hematoma, contributed to R1’s death. On August 11, 2025, PCC completed their review. The following was revealed and PCC concludes:
· R1 already had some chronic conditions with a history of stroke at admission to the facility.
· Given R1’s medical history, R1 had multiple coexisting conditions that made R1 prone to bleeding and increased risk for stroke.
· “According to CDC, previous stroke or transient ischemic attack increases the chances of having another stroke.”
· During a follow up appointment on September 4, 2024, there was no concern about further bleeding or any signs of stroke.

Based on this information obtained and a review conducted by PCC, there is insufficient evidence to prove that R1’s fall, which resulted in subdural hematoma, contributed to R1’s death. Therefore, the allegation of Questionable Death, is deemed Unsubstantiated at this time.

Staff did not respond to resident’s requests for assistance in a timely manner:
In regards to the allegation, it was reported that R1 was instructed to yell out for staff when requesting for assistance, instead of using the call button provided.

SUPERVISORS NAME: Angela J Whittaker
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20241121154006

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: HAVEN HOMES	FACILITY NUMBER: 197610327
	VISIT DATE: 08/29/2025

NARRATIVE

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Interview with the administrator deny the allegation. Administrator stated R1 and all facility residents are provided a portable push button device to carry with them to activate when assistance needed. On August 27, 2024, R1 had a fall, that caused damage to the portable push button device. Because of the damage to the device, R1 had to yell out for help. Staff did come to assist R1. Paramedics were called and R1 was taken to the hospital.

LPA was unable to interview Staff 1 (S1), as S1 no longer works at the facility. Interview with three (3) of three residents could not corroborate with the allegation of having to yell for staff assistance.

LPA conducted a physical plant inspection, and observed a push button device, provided to each resident in care. A test of this device proves to be functional. According to the three residents that were interviewed, there were no issues when utilizing this device.

Based on the information obtained, the allegation of staff not responding to resident requests for assistance in a timely manner could not be proven. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Angela J Whittaker
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

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