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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610626
Report Date: 12/02/2025
Date Signed: 12/02/2025 02:25:59 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 COMMUNITYFACILITY NUMBER:
197610626
ADMINISTRATOR:GUTIERREZ, CLAUDIAFACILITY TYPE:
740
ADDRESS:13641 FENTON AVETELEPHONE:
(818) 262-3871
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:6CENSUS: 5DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Claudia Gutierrez - AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not meeting residents nutritional needs
Staff are not mitigating the spread of infectious outbreaks in the facility
Staff are mismanaging residents medications
Staff did not seek timely medical attention for resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with Administrator Claudia Gutierrez and explained the reason for the visit.

LPA conducted a physical plant tour at 9:10 AM, requested copies of facility documents relevant to the investigation at 9:30 AM, reviewed records between 9:30 AM to 10:30 AM and interviewed staff and residents between 10:30 AM to 1:00 PM. Regarding the allegation that Staff are not meeting residents’ nutritional needs, it was alleged that the food quality and quantity has suffered at the facility. LPA's observation during today's visit revealed that today's menu consists of sauteed marinated chicken, rice, beans and salad with freshly prepared strawberry lemonade with honey fruit shake. LPA's interview with five (5) residents today between 10:30 AM to 1:00 PM revealed that all five (5) residents stated that they like the food here which is nutritious and delicious and the quality is very good and the quantity is sufficient. (continued on LIC 9099--C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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-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: 12/02/2025
NARRATIVE
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(continued from LIC 9099-C)

Regarding the allegation that Staff are not mitigating the spread of infectious outbreaks in the facility, it was alleged that there have been severe illnesses that resulted in hospitalization. LPA's record review today at 9:30 AM revealed that there was no record of any current or past client that has an infectious disease at the facility. LPA's interview with the staff revealed that there was no time that there was any resident admitted at the facility nor acquired any infectious disease while living at the facility.

Regarding the allegation that Staff are mismanaging residents’ medications, it was alleged that staff often missed Resident1 #1 (R1)'s medications. LPA's record review revealed that R1 was given all of R1's prescribed medication but it was R1 who refused some of R1's medication as noted in R1's Medication Administration Record (MAR). LPA's interview with staff today at 12:04 PM revealed that it was R1 who picked and chose medication to take at any given time so the staff noted in on R1's MAR.

Regarding the allegation that Staff did not seek timely medical attention for resident in care, it was alleged that R1 was discouraged from calling 911 at a time when R1 needed care. LPA's interview with the Administrator and staff between 10:30 AM to 1:00 PM, revealed that R1 had own phone and could have called 911 on R1's own and was not discouraged nor anyone at the facility to call 911. LPA's interview with five (5) residents during today's visit revealed that all five (5) of them stated that no one told or discouraged them from calling 911 when they needed to.

Based on the information gathered during this and prior 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: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2