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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850390
Report Date: 09/10/2026
Date Signed: 09/10/2026 03:36:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/25/2026 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20260825152629
FACILITY NAME:HOME SWEET HOME VAN BURENFACILITY NUMBER:
565850390
ADMINISTRATOR:VALENCIA, GLORIA P.FACILITY TYPE:
740
ADDRESS:7520 VAN BUREN STREETTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
09/10/2026
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Karthiga VijayakumarTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility is in disrepair
Staff do not ensure the residents rooms are clean and sanitary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. Upon arrival, LPA met with an Administrator Michelle Parr and explained the reason for the visit. Facility Manager Karthiga Vijayakumar arrived shortly thereafter.

During the initial visit on 08/26/26 LPA Cortez interviewed Manager Karthiga Vijayakumar and conducted interviews with two (2) guests and conducted a physical plant tour. During the investigation LPA interviewed a facility visitor and reviewed and discussed notes with LPA Cortez. During today's visit LPA toured the facility and interviewed staff.

Continue on 9099-C page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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 29-AS-20260825152629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME VAN BUREN
FACILITY NUMBER: 565850390
VISIT DATE: 09/10/2026
NARRATIVE
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Allegation: Facility is in disrepair

It was alleged the television has been broken for over a month with no sound.

On 8/26/26, LPA Cortez interviewed staff who acknowledged that the television sound was not working, stated that it had been repaired, and reported that it had recently malfunctioned again. Interviews conducted prior to arrival with witnesses confirmed that the television sound had not been functioning during multiple visits. During today’s visit, staff informed LPA Rankin that the television sound had previously not worked but had since started working; staff were unsure whether the television had been replaced or the sound issue repaired. LPA confirmed that as of today’s visit, the television sound was functioning.

LPA also observed that the flooring throughout the facility is beginning to split apart, resulting in small cracks and areas of peeling. This was noted in the living room, dining room, kitchen, laundry room, main hallway, and in two resident bedrooms. At this time, the concern is the flooring condition will soon pose a potential trip hazard for mobile residents, visitors, and staff.

The situation, at this time, did not pose an immediate health and safety risk to residents in care, this is considered a technical violation, and no citations are being issued at this time.

A Technical Violation is issued related to this allegation, for section 87307 (d)(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

Allegation: Staff do not ensure the residents’ rooms are clean and sanitary

It was alleged that residents’ rooms are filthy, with cobwebs and dirty floors.

On 9/10/26, LPA Rankin conducted a tour of the facility. LPA observed minimal debris on the bedroom floors and did not observe any cobwebs in residents’ rooms at the time of the visit. However, LPA noted that resident bathrooms had multiple areas of concern. Continue on 9099-C page 3
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20260825152629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME VAN BUREN
FACILITY NUMBER: 565850390
VISIT DATE: 09/10/2026
NARRATIVE
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LPA observed cobwebs in the corner of the window above the stove. Several kitchen cabinet doors appeared soiled, with visible brown spotting and residue. The wall and floor near the refrigerator contained dirt and spill marks. Baseboards throughout the facility had a noticeable layer of thick dust and dirt.
The resident bathrooms also showed significant concerns: the tile grout around both showers/tubs was dark brown to black in color, with visible grime along the ledges. The bases of the toilets and the surrounding floor areas had urine residue and additional dirt and grime buildup.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Based on observation and interview, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Copy of report and appeal rights printed and provided to facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20260825152629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HOME SWEET HOME VAN BUREN
FACILITY NUMBER: 565850390
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87470(a)(2)(A)(B)
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87470 Infection Control Requirements(a)A licensee shall ensure that infection control practices are maintained as follows:(2) Environmental cleaning and disinfection activities shall be performed…These activities shall be completed, at a minimum...:(A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above when they failed to conduct routine infection control maintenance and cleaning in the bathroom, kitchen, and along the baseboards and flooring throughout the facility which poses a potential health and safety risk violation to residents in care.
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on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with…body fluids or other potentially infectious material. (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled.
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POC: Facility will have an initial deep cleaning done by a professional, images of bathroom showers and kitchen area will be sent to LPA. A routine schedule will be created and emailed to LPA.
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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.
SUPERVISOR'S NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/25/2026 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20260825152629

FACILITY NAME:HOME SWEET HOME VAN BURENFACILITY NUMBER:
565850390
ADMINISTRATOR:VALENCIA, GLORIA P.FACILITY TYPE:
740
ADDRESS:7520 VAN BUREN STREETTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE:CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
09/10/2026
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Karthiga VijayakumarTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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2
3
4
5
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7
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9
Staff do not ensure resident is provided a comfortable environment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. Upon arrival, LPA met with an Administrator Michelle xxxx and explained the reason for the visit. Facility Manager Karthiga Vijayakumar arrived shortly thereafter.

During the initial visit on 08/26/26 LPA Cortez interviewed Manager Karthiga Vijayakumar and conducted interviews with two (2) guests and conducted a physical plant tour. During the investigation LPA interviewed a facility visitor and reviewed and discussed notes with LPA Cortez. During today's visit LPA toured the facility and interviewed staff.
Allegation: Staff do not ensure resident is provided a comfortable environment

It was alleged that staff are not providing a comfortable environment and that the facility has been hot. During the original visit on 8/26/26, the temperature inside a resident’s room reached 90 degrees. This concern was already addressed and substantiated on 8/26/26 under a separate allegation. It is unclear what additional issues this allegation intended to address; therefore, this allegation is determined to be unsubstantiated based on the concern already cited.
A copy of this report was read and printed for the administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5