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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610707
Report Date: 04/01/2026
Date Signed: 04/01/2026 02:08:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
10/21/2025 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20251021101610
FACILITY NAME:AVERIE MANORFACILITY NUMBER:
197610707
ADMINISTRATOR:JOSEPH, ABRAHAMFACILITY TYPE:
740
ADDRESS:23241 VIA CALISEROTELEPHONE:
(323) 788-0866
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 1DATE:
04/01/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Abraham Joseph, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff dropped resident during a transfer resulting in injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with licensee Abraham Joseph and explained the reason for the visit.

--- Facility staff dropped resident during a transfer resulting in injury.

It was alleged that Resident #1 (R1) was not transferred safely and dropped to the ground sustaining multiple fractures. To investigate the allegation, on October 21, 2025, LPA requested documents at around 10:00a.m. On November 6, 2025, the department conducted interviews with two (02) staff at around 11:30a.m. On November 7, 2025, the department requested additional documents from other parties. A review of hospital X-ray records noted a fracture to R1’s left femur resulting in an acute distal femoral fracture.
(CONT on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
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 5
Control Number 31-AS-20251021101610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AVERIE MANOR
FACILITY NUMBER: 197610707
VISIT DATE: 04/01/2026
NARRATIVE
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The caregivers who were interviewed gave inconsistent information as to how R1 was transferred on October 12, 2025, which resulted in their injury. The two caregivers present were previously instructed to be in front of and behind R1 to assist with transferring. One of the caregivers stated she was on the left side of R1 when assisting. The other caregiver stated he was behind R1 as he was instructed by the private caregiver and hospice nurse.

Based on interviews and record reviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards were noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20251021101610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AVERIE MANOR
FACILITY NUMBER: 197610707
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2026
Section Cited
CCR
87464(f)(2)
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87464 Basic Services (f)Basic services shall at a minimum include…(2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by; Based on interviews, R1
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Licensee will provide training on safe transfer techniques and review policy. Licensee will submit a written letter stating they have reviewed regulation and going forward will adhere to it.
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was not transferred as instructed leading to injury which poses an immediate health, safety and personal rights 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
10/21/2025 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20251021101610

FACILITY NAME:AVERIE MANORFACILITY NUMBER:
197610707
ADMINISTRATOR:JOSEPH, ABRAHAMFACILITY TYPE:
740
ADDRESS:23241 VIA CALISEROTELEPHONE:
(323) 788-0866
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 1DATE:
04/01/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Abraham Joseph, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee does not ensure that staff are adequately trained.
Staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with licensee Abraham Joseph and explained the reason for the visit.

--- Licensee does not ensure that staff are adequately trained.

It was alleged that facility staff are not properly trained. To investigate the allegation, on April 1, 2026, the Department reviewed documents at around 11:00a.m. and interviewed one staff from 11:30a.m. – 12:00p.m. A review of the facility's staff records revealed all staff completed required training at the time of the alleged incident.

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

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20251021101610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AVERIE MANOR
FACILITY NUMBER: 197610707
VISIT DATE: 04/01/2026
NARRATIVE
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During interviews, staff stated all staff have completed training and background clearances.

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

--- Staff did not follow reporting requirements.

It was alleged that facility did not submit an incident report. To investigate the allegation, on April 1, 2026, the Department reviewed documents at around 11:00a.m. and interviewed one staff from 11:30a.m. – 12:00p.m. A review of the Department’s records revealed facility submitted a written report within seven (07) days of the occurrence. During interviews, staff stated the resident’s Responsible Party was at the facility within a few hours of the incident taking place.

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

No other health and safety hazards were noted during the visit.
Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5