197610405-8-12-2026-31-AS-TAGD-DXSS5V-20260910133458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610405
Report Date: 08/12/2026
Date Signed: 08/12/2026 03:31:11 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.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
05/20/2026 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20260520093344

FACILITY NAME:	A HUMBLE ABODE INC		FACILITY NUMBER:	197610405
ADMINISTRATOR:	BUNGABONG, SILICA		FACILITY TYPE:	740
ADDRESS:	25703 WHISPERING TREES WAY		TELEPHONE:	(818) 428-5352
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2026
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jorge Aquino		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not address a resident's change in medical condition in a timely manner.
Staff do not respond to residents call for help in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with the House Manager, Jorge Aquino, and explained the reason for the visit.

--- Staff did not address a resident's change in medical condition in a timely
manner

It was alleged that Resident #1 (R1) was experiencing abdominal and pelvic pain and pain related to catheter use for over one (1) week. To investigate the allegation, on May 22, 2026, LPA requested documents and interviewed one (1) staff. Today, LPA interviewed two (2) additional staff and four (4) out of five (5) residents from around 1:00p.m. to 2:30p.m. LPA was unable to interview R1 as they are no longer in the home. A review of R1’s Physician’s Report states they have a primary diagnosis of dementia, bladder incontinence, history of UTI, not able to care for own toileting needs and has temper bouts. (CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

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-20260520093344

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: A HUMBLE ABODE INC	FACILITY NUMBER: 197610405
	VISIT DATE: 08/12/2026

NARRATIVE

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A review of R1’s Needs and Service Plan states R1 has increased agitation and combative behavior, age related cognitive decline with frequent forgetfulness, requires step-by-step guidance, verbal prompts and simplified instructions. During interviews, all staff stated they address R1’s needs immediately. S1 added, when R1 felt pain that day from the catheter, staff contacted emergency services immediately and, as instructed, contacted the responsible party. All interviewed residents stated staff respond to all their needs timely.

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

--- Staff do not respond to residents call for help in a timely manner.

It was alleged that R1 must yell or scream to obtain staff attention. To investigate the allegation, on May 22, 2026, LPA requested documents and interviewed one (1) staff. Today, LPA interviewed two (2) staff and four (4) out of five (5) residents from around 1:00p.m. to 2:30p.m. LPA was unable to interview R1 as they are no longer in the home. A review of staff schedule shows there are always at least two caregivers in the facility. During interviews, all staff stated they check on residents every hour or more if needed. S1 added some residents are less patient than others but that caregivers always respond timely. All residents stated staff respond to calls for assistance timely.

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

No 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: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC9099 (FAS) - (06/04)

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