197610626-8-26-2025-31-AS-TAGD-DPNVB8-20251224151705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610626
Report Date: 08/26/2025
Date Signed: 08/26/2025 02:09:41 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
08/19/2025 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20250819145821

FACILITY NAME:	A PEACEFUL HAVEN RESIDENTIAL COMMUNITY		FACILITY NUMBER:	197610626
ADMINISTRATOR:	GUTIERREZ, CLAUDIA		FACILITY TYPE:	740
ADDRESS:	13641 FENTON AVE		TELEPHONE:	(818) 262-3871
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 4	DATE:	08/26/2025
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Lucy Guttierez - Co Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff do not ensure resident restrooms are clean and orderly

Staff are not properly cleaning dishes used for residents

Staff do not ensure all persons engaged in food preparation are practicing proper hygiene to prevent contamination.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with co Administrator Lucy Guttierez and explained the reason for the visit.

LPA conducted a physical plant tour at 9:38 AM, requested copies of facility documents relevant to the investigation at 10:00 AM, reviewed records between 10:00 AM to 11:00 AM and interviewed staff and residents between 11:00 AM to 1:30 PM. Regarding the allegation that Staff do not ensure resident restrooms are clean and orderly, it was alleged that there have been continuous issues with unsanitary conditions in the restroom. LPA's observation during this visit and prior visit on 08/19/25 while investigating complaint control no.: 31-AS-20250814152448, revealed that the residents' bathrooms are clean and in proper order. LPA's interview with three (3) residents present during this visit revealed that three (3) out of three (3) residents stated that the bathrooms are always clean and in proper order and they never had any issue with the bathroom. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250819145821

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: A PEACEFUL HAVEN RESIDENTIAL COMMUNITY	FACILITY NUMBER: 197610626
	VISIT DATE: 08/26/2025

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff are not properly cleaning dishes used for residents, it was alleged that states dishes are not cleaned properly, LPA's observation during this visit and prior visit on 08/19/25 while investigating complaint control no.: 31-AS-20250814152448, revealed that the unused dishes, pots and pans, cups, glasses, plates etc., were all observed to be clean and kept properly in the dish cabinet. LPA's interview with three (3) residents present during this visit revealed that three (3) out of three (3) residents stated that the plates and utensils they use are always clean and the food is good. LPA's interview with the staff during this visit also revealed that the staff always used the dishwashing machine to clean the dishes and utilities.

Regarding the allegation that Staff do not ensure all persons engaged in food preparation are practicing proper hygiene to prevent contamination, it was alleged that the staff and have prepared food while sick or coughing and do not use proper equipment to ensure contamination and good hygiene are upheld. LPA's record review today between 10:00 AM to 11:00 AM revealed that the staff had multiple certifications on food handling not only in California but also at Washington State, the staff obtained a food handler permit on 11/08/24 and has a food worker card from Washington state Public Health. LPA's observation today while the staff was preparing food also revealed that the staff was wearing gloves, hair tied neatly and prepared the food in delicate manner.

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: 08/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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