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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850595
Report Date: 09/29/2025
Date Signed: 09/29/2025 03:12:04 PM

Substantiated


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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2025 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20250903123420
FACILITY NAME:HOME SWEET HOME NEWMANFACILITY NUMBER:
565850595
ADMINISTRATOR:KANAKARAJ, KARTHIKFACILITY TYPE:
740
ADDRESS:5638 NEWMAN STTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 4DATE:
09/29/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Karthik (Raj) Kanakaraj & Karthiga (Karthi) VijayakumarTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff mishandled a resident's medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the above noted allegations. LPA met with both Administrator and facility designee at 12:10PM. Entrance interview conducted.

During today's visit, LPA interviewed residents and their family members from 12:14PM to 12:45PM, interviewed management, and reviewed additional documents. During an initial visit conducted on 09/10/2025, LPA conducted a tour of the facility at 04:29PM, interviewed Administrator and Designee at 03:25PM, and reviewed and obtained copies of pertinent documents. During a subsequent complaint visit conducted on 09/17/2025, LPA interviewed staff at 03:59PM and 04:10PM and observed residents. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic and in person interviews with additional relevant parties. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
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 6
Control Number 29-AS-20250903123420
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME NEWMAN
FACILITY NUMBER: 565850595
VISIT DATE: 09/29/2025
NARRATIVE
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The complaint alleges that prior to moving into the facility, Resident #1 (R1) took pain medications PRN (as needed.) Typically, R1 would only request this PRN medication every few days prior to moving into the facility. Interviews revealed that R1 previously lived with a family member and that on 08/01/2025 R1 went to the hospital due to R1’s family member also being hospitalized, as R1 required assistance with activities of daily living (ADLs.) Records reviewed for R1 indicate R1 has chronic low back pain, knee pain and was diagnosed “failure to thrive” after the incident with the family member that occurred in their private home. R1 moved into the facility on 08/06/2025, however interview with management revealed that R1 came to the facility with no medications. Medications had a fill date of 08/07/2025 and were documented as administered beginning 08/08/2025. Interview with staff and R1 revealed that R1 is able to communicate their needs and could request PRN medications, however facility did not have a PRN authorization form for R1. Staff interviewed stated that R1 verbalized they were in pain and staff would give R1 a PRN hydrocodone-acetaminophen when requested. LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) and photographs provided of R1’s hydrocodone-acetaminophen 5-325 bottle which indicates “take 1 tablet by mouth every 6 hours as needed.” However, R1’s medical assessment and hospital paperwork both indicate R1’s hydrocodone-acetaminophen 5-325 is prescribed BID (twice a day) PRN. LPA did not receive any documentation indicating whether the facility attempted to clarify this discrepancy in orders. Review of Medication Administration Record (MAR) for R1 revealed that R1 was administered this medication from 08/08/2025 through 08/10/2025 twice a day. Beginning on 08/11/2025 through 08/17/2025, it was administered 4 (four) times a day, at regular 6-hour intervals. Then on 08/18/2025, staff indicated the medication was administered at 12 midnight, 02AM, and 10 noon. There was no indication this medication was administered after 08/18/2025. R1 moved out of the facility on 08/21/2025. There were 45 (forty five) pills when the bottle was filled and the facility has documentation of 36 (thirty six) times the medication was administered, so there should have been 9 (nine) pills remaining in the bottle when R1 moved out. According to R1’s family member, there were 3 (three) pills remaining when the medication was removed from the facility. LPA was unable to confirm this information as there is no documentation at the facility of the medication amounts taken with the resident. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “staff mishandled a resident’s medications” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Staff was informed that failure to correct to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of today’s report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250903123420
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOME SWEET HOME NEWMAN
FACILITY NUMBER: 565850595
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2025
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Administrator agreed to provide medication training for caregivers and will get a PRN authorization form for all residents using PRN medications. Proof of training and authorization forms will be provided to CCL by POC due date.
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Based on interview and record review, the licensee did not comply with above cited section, as medications were not administered until 2 days after move in, PRN medications was given 2 hours apart, and facility did not get clarification on medication orders or a PRN authorization, which posed
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a potential health risk to persons 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2025 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20250903123420

FACILITY NAME:HOME SWEET HOME NEWMANFACILITY NUMBER:
565850595
ADMINISTRATOR:KANAKARAJ, KARTHIKFACILITY TYPE:
740
ADDRESS:5638 NEWMAN STTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 4DATE:
09/29/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Karthik Kanakaraj & Karthiga VijayakumarTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not have planned activities for a resident
Staff mishandled a resident's personal belonging
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the above noted allegations. LPA met with both Administrator and facility designee at 12:10PM. Entrance interview conducted.

During today's visit, LPA interviewed residents and their family members from 12:14PM to 12:45PM, interviewed management, and reviewed additional documents. During an initial visit conducted on 09/10/2025, LPA conducted a tour of the facility at 04:29PM, interviewed Administrator and Designee at 03:25PM, and reviewed and obtained copies of pertinent documents. During a subsequent complaint visit conducted on 09/17/2025, LPA interviewed staff at 03:59PM and 04:10PM and observed residents. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic and in person interviews with additional relevant parties. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
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 6
Control Number 29-AS-20250903123420
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME NEWMAN
FACILITY NUMBER: 565850595
VISIT DATE: 09/29/2025
NARRATIVE
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Allegation “Staff did not have planned activities for a resident:”

The complaint alleges that Resident #1 (R1) did not have activities available during the time they lived at the facility and that R1 was left in their room during the day without a functional television. LPA interviewed residents and staff related to the allegation, as well as R1 and their family member. Record review and interview revealed that R1 resided at the facility from 08/06/2025 to 08/21/2025. R1’s medical assessment dated 08/06/2025 indicates R1 is bedridden with a comment indicating R1 “is unable to ambulate due to contracted legs from being immobile and sitting in a recliner for over 2 years.” Interview revealed that R1 did remain in their room due to their ambulatory status, however the facility has an activity coordinator who visits the facility twice a week. Activity coordinator stated R1 was unable to join in group activities in common areas of the facility, but activity coordinator visited with the resident in R1’s room and engaged R1 in activities on the ipad. R1 was offered card games and other activities but declined those offers. Interviews revealed facility staff also conversed with R1 and offered additional activities, however R1 chose not to participate in activities due to chronic pain. Interview with R1 revealed they remained in their room and watched television during waking hours. Interview with residents revealed the facility does offer activities to the residents, should they wish to participate. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "staff did not have planned activities for a resident" is deemed Unsubstantiated at this time.

Allegation “Staff mishandled a resident’s personal belonging:”

According to the complainant, R1’s cell phone was confiscated while R1 was residing at the facility. Management interviewed stated R1 had brought a red flip phone with them when they moved into the facility, but that no charger was brought for the phone. Management indicated they did not have the appropriate charger so they were initially unable to assist R1 in charging their phone battery. Even when additional personal items were brought in for R1, no phone charging cord was provided. LPA reviewed all documents for R1, including a blank personal property inventory, so LPA was unable to determine which personal items R1 may have had with them while residing at the facility. Managers interviewed indicated they did procure an appropriate cord to charge R1’s phone after R1 had been at the facility a few days. Staff interviewed indicated that due to R1’s physical condition, R1 was unable to plug their phone in to charge it

Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20250903123420
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME NEWMAN
FACILITY NUMBER: 565850595
VISIT DATE: 09/29/2025
NARRATIVE
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independently. Staff stated R1 preferred to hold their phone to their chest and did not wish for staff to handle their phone. However, in order for the phone to charge, they had to take the phone and plug it into the outlet closest to R1’s bed, which reportedly upset R1. Interviews revealed that all residents maintain their personal belongings in their private rooms and staff do not take residents’ personal belongings. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "staff mishandled a resident’s personal belonging" is deemed Unsubstantiated at this time.

No deficiencies cited relating to the above allegations. Exit interview conducted. A copy of the report was provided

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6