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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610405
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:47:13 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
02/09/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240209105707
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: 4DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Jorge Aquino, House ManagerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff not preventing resident from getting physically abused.
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 House Manager, Jorge Aquino, and explained the reason for the visit.

--- Staff not preventing resident from getting physically abused.

It was alleged that Resident #1 (R1) is being physically abused by unknown perpetrator. To investigate the allegation, on 02/16/2024, interviewed four (04) staff from 10:45 AM – 12:00 PM and interviewed three (03) out of four (04) residents from around 12:15 PM – 01:45 PM. During interviews with staff, all staff stated they have never physically harmed any resident and are not aware of any others abusing residents.

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

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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 2
Control Number 31-AS-20240209105707
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: 02/16/2024
NARRATIVE
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During interviews with residents, three (03) out of four (04) residents stated they have never been physically abused by staff, including R1. LPA was unable to interview one (01) resident.

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

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: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2