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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610379
Report Date: 03/12/2026
Date Signed: 03/12/2026 02:40:06 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
03/09/2026 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20260309151025
FACILITY NAME:MY HOME FACILITYFACILITY NUMBER:
197610379
ADMINISTRATOR:HASMIK NSHANYANFACILITY TYPE:
740
ADDRESS:19837 SEPTO STREETTELEPHONE:
(830) 505-5505
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 6DATE:
03/12/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hasmik Nshanyan, Administrator TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff not transporting resident(s) to scheduled appointments.
Staff yell at residents.
Lack of supervision resulting in resident being physically assaulted by another resident.
Staff do not assist resident.
Staff do not prevent resident from disturbing another resident sleep..
Staff do not administer residents medications as prescribed.
Staff do not allow residents access to available bathroom.
Facility is not providing adequate food service for residents.
INVESTIGATION FINDINGS:
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At 09:00am, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi conducted an unannounced visit in response to the above-mentioned allegations. LPAs met with the Administrator and explained the reason for the visit.

At 09:05am, LPAs requested residents and staff roster. At 09:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Centrally Stored Medication and Destruction Record (CSMR), Medication Administration Record (MAR), Menu and Staff Training relevant to the investigation. At approximately 09:15am, LPA conducted a physical plant tour. Between 09:20am – 11:00am, LPA conducted an interview with the Administrator, two (2) staff, and four (4) out of six (6) residents, who were able to communicate.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
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 6
Control Number 31-AS-20260309151025
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: MY HOME FACILITY
FACILITY NUMBER: 197610379
VISIT DATE: 03/12/2026
NARRATIVE
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Allegation: Staff not transporting resident(s) to scheduled appointments.

It was alleged that facility staff are not transporting R1 to their scheduled appointments. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that R1 was transferred to this facility from Santa Barbara County and R1’s insurance was not transferable from county to county. In order for R1 to be seen by a doctor in Los Angeles County, the Administrator took R1 to Social Security Administration Office on 02/25/25. However, the representative was unable to assist and scheduled an appointment for 03/17/26. In a meanwhile, the Administrator contacted the Sanctuary Centers of Santa Barbara (CSB) and requested a zoom appointment for R1. The request was granted and the appointment was scheduled for 03/09/2026 at 2:00pm. LPA was informed that right before the telephonic visit, R1 informed the Administrator that he/she does not wish to attend the appointment and refused to connect to the zoom. LPA contacted the CSB and confirmed that due to R1’s refusal the appointment was canceled/rescheduled. Moreover, LPAs were informed that on 02/27/26 R1 was taken do Dr's office for a blood test, however, the doctor's office informed that the lab test must be done through Quest Diagnostics. S2 immediately drove to the Quest, but R1 refused to get out of the car. The following appointment was scheduled for 03/02/26, however, the blood test was again canceled due to the lack of R1's valid Identification. During today’s visit, LPAs also conducted interviews with three (4) residents and was informed that the staff always arranges and or provides transportation for all their doctor’s appointments. Three (3) residents interviewed expressed no concern regarding this allegation. Therefore, based on interviews and record reviews, this allegation is deemed Unsubstantiated, at this time.

Allegation: Staff yell at residents.

It was alleged that R1 asked for toilet paper and S1 got mad and yelled at R1. To investigate this allegation LPAs conducted an interview with the Administrator and two (2) staff members and all parties interviewed denied the above allegation. LPAs were informed that every morning and evening the staff conduct round checks to make sure all toilet supplies are intact and available for residents’ use. Three (3) out of four (4) residents interviewed expressed no concern regarding this allegation and confirmed that staff communicate appropriately. Residents reported that it is R1 who yells and causes disturbances, not staff. During today’s visit LPAs observed staff treating residents in a professional and respectful manner. Therefore, based on interviews and LPAs observation, this allegation is deemed Unsubstantiated, at this time.

Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20260309151025
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: MY HOME FACILITY
FACILITY NUMBER: 197610379
VISIT DATE: 03/12/2026
NARRATIVE
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Allegation: Lack of supervision resulting in resident being physically assaulted by another resident.

It was alleged that R1 was physically assaulted by a R2. It was also reported that R2 grabbed R1 by his/her neck and hair. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that R2 had been living at this facility for over one (1) year. During R2’s entire stay the Administrator did not observe R2 being physically and or verbally aggressive towards other residents/staff. However, R1 was admitted to this facility on 02/02/26, and showed numerous aggressive behaviors towards the residents and staff. Administrator also informed LPAs that the facility staff being aware of R1’s aggressive behavior always keep an eye on R1, so that they can immediately de-escalate the situation, if any. Administrator stated: “Due to R1’s mental status, R1 is not suitable for this facility. I also had a discussion with R1’s Case Worker who informed me that they will actively look for an alternative placement. I will have to issue an eviction letter to R1 today.” Furthermore, during the interview with S1, LPAs were informed that an incident occurred on 03/09/26, around 5:00pm. S1 stated that they were talking to R2 by the kitchen area, and R1 came out from his/her room, already looking aggressive, and pushed S1 against the wall and attacked R2. R2 asked R1 to back up and stay away from them. R2 also informed R1 that they will call 911 and press charges against them. Although two (2) officers responded to 911 call, no police report was filed due to both parties (R1 and R2) wanting to press charge against each other. Officers advised both residents to file restraining orders through the court and stay away from each other. Interview with three (3) residents confirmed the statement provided by the Administrator and S1 and all residents interviewed denied that "lack of supervision" was a factor in the incident. LPAs were informed that the staff is always available and provided excellent supervision and protect residents from being physically/verbally assaulted. Lastly, LPA conducted review of the Incident Reports and observed that the facility did submit a written incident to the Regional Office in a timely manner. Therefore, based on interviews and record reviews this allegation is deemed Unsubstantiated, at this time.

Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20260309151025
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: MY HOME FACILITY
FACILITY NUMBER: 197610379
VISIT DATE: 03/12/2026
NARRATIVE
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Allegation: Staff do not assist resident.

It was alleged that facility staff do not assist residents when assistance is requested. To investigate this allegation, LPAs conducted an interview with the Administrator, S1 and S2 and all parties interviewed denied the above allegation and stated that staff respond promptly when residents call. Staff explained that residents who require additional attention are immediately attended to, and assistance is provided continuously throughout the day and night. Three (3) out of four (4) residents confirmed that staff provide assistance as requested. Residents reported that R1’s behavior sometimes disrupts care delivery but did not indicate that staff refuse or fail to assist other residents. Therefore, based on interviews this allegation is deemed Unsubstantiated, at this time.

Allegation: Staff do not prevent resident from disturbing another resident sleep.

It was alleged that staff do not prevent residents from disturbing R1 during sleep hours. To investigate this allegation LPAs conducted interviews with the Administrator, S1 and S2 and all parties interviewed denied the above allegation and stated that five (5) out of six (6) residents have been living at this facility for over one (1) year and they never had any complaints regarding residents disturbing each others sleep. However, R1 moved to this facility on 02/02/26 and every morning, around 5am, R1 speaks very loudly and knocks on every residents' door. Staff is always available to redirect and calm R1 down, however, R1 occasionally creates noise due to their mental diagnosis. During today's entire visit, LPAs observed R1 walking from door-to-door to make sure that all residents are in their rooms. LPAs observed that R1 continuously disturbing residents privacy and the staff provides redirection. Therefore, based on interviews and LPAs observation, this allegation is deemed Unsubstantiated, at this time.





Continue on LIC9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20260309151025
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: MY HOME FACILITY
FACILITY NUMBER: 197610379
VISIT DATE: 03/12/2026
NARRATIVE
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Allegation: Staff do not administer residents medications as prescribed.

It was alleged that staff do not administer medications as prescribed. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that the staff had been properly trained on medication administration and always assist residents with their medications as prescribed. Interview with S1 and S2 confirmed the statement provided by the Administrator and informed LPAs that all medications are properly documented. LPAs conducted review of three (3) random medications for R1 and R2. LPAs also counted the medications and compared to CSMDR and MAR and observed no discrepancy. Lastly, three (3) out of four (4) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews, record reviews and medication count, this allegation is deemed Unsubstantiated, at this time.

Allegation: Staff do not allow residents access to available bathroom.

It was alleged that multiple residents are waiting in line to use the bathroom because staff does not allow residents access to available bathroom. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that the facility has three (3) bathrooms, of which one (1) is in room #2 (master bedroom) for R2 use only. The second bathroom is located by bedroom #4 and is available for all residents and the third bathroom ("staff only"). LPAs were also informed that three (3) out of six (6) residents do not use bathrooms due to incontinence. R1 and R3 have shared bathroom available for use, however, if necessary, the staff will allow them to also use the "staff bathroom". Three (3) out of four (4) residents interviewed expressed no concern regarding this allegation. LPAs were informed that they are able to go to the bathroom on their own and never had to "wait in line." During today's visit, LPAs did not observe residents being denied access to bathrooms. Based on interviews and LPAs observation this allegation is deemed Unsubstantiated, at this time.


Continue on LIC9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20260309151025
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: MY HOME FACILITY
FACILITY NUMBER: 197610379
VISIT DATE: 03/12/2026
NARRATIVE
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Allegation: Facility is not providing adequate food service for residents.

Staff are not providing adequate food service to residents in care. It is being alleged that the food portions are small, and that staff are not meeting R1’s dietary needs. LPAs interviewed three (3) out of four (4) residents, who were able to communicate and were informed that the food portions are sometimes small but they can ask for more. All residents interviewed stated that food choices are sufficient and there is always fruit, vegetables and alternative choices available daily. Staff stated that food quality and portions are good and balanced. Facility provides three meals, which includes vegetables, fruits, salad and dessert with a secondary menu for residents who do not like the meal of the day, as additional options. Residents may ask for more food, which is provided throughout the day/night. Residents can notify the caregivers of their food preferences, if they don't like the food of the day and the staff will prepare a different meal for them. During todays visit, LPAs observed balanced/nutritious lunch being served to six (6) residents, which include: vegetable soup with noodles, ham sandwich with cheese, lettuce, tomato and avocado, along with cookies and bowl for fruits. LPAs were also informed that R4's meals are prepared based on physician's instructions and the staff follows R4's dietary needs. LPAs observed sufficient supply of perishable (2 days) and non-perishable (7 days) food items in the pantries, refrigerators and freezers. LPAs obtained copy of facility's three (3) week menu in which a diet for residents with meat or vegetable preference can be observed. Based on interviews and LPAs observation this allegation is deemed Unsubstantiated, at this time.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6