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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610437
Report Date: 08/06/2024
Date Signed: 08/06/2024 02:26:54 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.ASC, 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
08/05/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240805120248
FACILITY NAME:SYLMAR BOARD & CAREFACILITY NUMBER:
197610437
ADMINISTRATOR:OVAKIMYAN, ANIFACILITY TYPE:
740
ADDRESS:13100 FELLOWS AVETELEPHONE:
(818) 665-9631
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:6CENSUS: 5DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Andy Terner - Co AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not following resident's special diet order

Staff speak inappropriately to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with co- Administrator Andy Terner and explained the reason for the visit.

LPA conducted physical plan tour at 9:15 AM, requested copy of facility documents relevant to the investigation at 9:55 AM, reviewed facility documents between 9:55 AM to 10:45 AM and interviewed residents between 11:00 AM to 12:45 PM. Regarding the allegation that Staff speak inappropriately to resident, it was alleged that staff told Resident #1 (R1) will make R1 pay for toilet paper. LPA's interview with R1 today at 11:00 AM revealed that the staff and facility owner provided everything R1 needed and did not have to pay for it. LPA's interview with three (3) residents between 11:00 AM to 12:45 PM revealed that all three (3) of them did not experience nor heard or witnessed any staff speaking inappropriately or asked to pay for anything in the facility. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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-20240805120248
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SYLMAR BOARD & CARE
FACILITY NUMBER: 197610437
VISIT DATE: 08/06/2024
NARRATIVE
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(continued from LIC 9099)

Regarding the allegation that Staff are not following resident's special diet order, LPA's interview with R1 today revealed that the staff prepares food in accordance with R1's diet. LPA's interview with the staff today at 12:02 PM confirmed that the staff had a renal diet guide in the kitchen for preparing R1's food. LPA's record review today between 9:45 AM to 10:45 AM revealed that there are two (2) residents at this facility on renal diet. LPA's interview with Resident #2 (R2) confirmed that the staff prepared their food based on the guidelines provided to the staff, usually no or very little salt with a lot of fruits and vegetables. LPA observed that the staff prepared cauliflower, spinach and couscous soup with watermelon and cantaloupe for lunch for their renal diet residents.

Based on the information gathered during this visit, these allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2