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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610405
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:53:12 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
11/27/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20231127111119
FACILITY NAME:A HUMBLE ABODE INCFACILITY NUMBER:
197610405
ADMINISTRATOR:BUNGABONG, SILICAFACILITY TYPE:
740
ADDRESS:25703 WHISPERING TREES WAYTELEPHONE:
(818) 428-5352
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 5DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:James Contreras, LicenseeTIME COMPLETED:
04:03 PM
ALLEGATION(S):
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Staff did not seek medical care for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the Licensee James Contreras and explained the reason for the visit.

--- Staff did not seek medical care for resident

It was alleged that the facility did not seek emergency services for resident attempting suicide. To investigate the allegation, on 11/30/2023, LPA requested records at 10:15 AM, interviewed two (02) staff from 10:45 AM – 11:30 AM and interviewed one (01) out of five (05) residents from around 11:45 AM – 12:15 PM. LPA was unable to interview all other residents. A review of Resident #1’s (R1) Physician’s Report shows that R1 is not a suicide risk. During interviews with staff, all staff stated R1 attempted suicide and admitted to not seeking emergency or medical services for R1.
(CONT. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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 3
Control Number 31-AS-20231127111119
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: A HUMBLE ABODE INC
FACILITY NUMBER: 197610405
VISIT DATE: 11/30/2023
NARRATIVE
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Staff added that they intended to seek medical attention but that services were initiated the following day by a third-party representative who was made aware of the incident by R1. During interviews with resident, R1 stated they attempted to commit suicide and medical attention was initiated after the incident but is not aware of who contacted medical services.

Based on interviews, 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 health and safety hazards were noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20231127111119
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: A HUMBLE ABODE INC
FACILITY NUMBER: 197610405
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87465(a)(2)
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 Incidental Medical and Dental Care(a) A plan for incidental medical…care..shall be developed by each facility. The plan shall…provide for assistance in obtaining such care, by compliance with the following:(2) The licensee shall provide assistance in meeting necessary medical...needs.
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87465 Incidental Medical and Dental Care; The written letter must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by; Based on interviews, facility did not provide assistance in meeting necessary medical needs after a serious incident which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
12/01/2023
Section Cited
CCR
87464(f)(6)
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87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, …, as specified in Section 87465, Incidental Medical and Dental Care Services... This requirement is not met as evidenced by:
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87464 Basic Services; The written letter must be sent to the LPA by the POC due date.
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 Based on interviews, facility did not arrange to meet residents’ health needs after a serious incident which poses an immediate 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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3