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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610405
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:54:12 PM

Document Has Been Signed on 11/30/2023 03:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:James Contreras, LicenseeTIME COMPLETED:
03:17 PM
NARRATIVE
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This LIC 809 is being created in conjunction with a complaint visit done today at the above-named address (complaint control number 31-AS-20231127111119). During the initial complaint visit, LPA Duguma discovered that facility staff did not report an incident that took place at the facility on the evening of 11/23/2023. Resident #1, who was not deemed a suicide risk, attempted to commit suicide and staff walked in, stopped the attempt, removed everything dangerous that might be used and reported the incident to their superior. A review of the departments records confirms that facility did not submit an Incident Report and facility failed to contact medical service. Failure to contact medical services was addressed on the complaint via LIC9099 and LIC9099-D.

Per CCR, Title 22, Division 6, Chapter 8, the following is noted as a result of the visit:


(see LIC 809-D for any deficiencies cited).

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 03:54 PM - It Cannot Be Edited


Created By: Abeye Duguma On 11/30/2023 at 03:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
12/04/2023
Section Cited
CCR
87211(a)(1)(D)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require,...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...
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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 87211 Reporting Requirements; The written letter must be sent to the LPA by the POC due date.
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(D)Any incident which threatens the welfare, safety or health of any resident.
This requirement is not met as evidenced by; Based on interviews, facility did not submit incident report to the Dept. which poses a potential health, safety and personal rights risk to resident 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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