Complaint Investigation Report
Allegation: “Staff did not ensure reporting requirements were followed”
It was reported that the facility did not follow reporting requirements when Resident #1 (R1) was transported to the hospital on 11/30/2025. Specifically, North Los Angeles County Regional Center (NLACRC) and Department of Developmental Services (DDS) were not notified within a twenty-four (24) hour period. Per Health and Safety Code Section 1538.55(a), “The licensee of an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN)… shall report to the department’s Community Care Licensing Division, within the department’s next working day and to the regional center with whom the ARFPSHN or the GHCSHN contracts, and the State Department of Developmental Services, within 24 hours upon the occurrence of any of the following events…”
Record review revealed that facility HM Betty Davis notified two (2) NLACRC staff and included the facility’s Interim Administrator and secondary House Manager Nancy Reyes on 11/30/2025 via email. LPA Huynh was forwarded the notification shortly after the initial notification. NLACRC Nurse Consultant confirmed receipt of the notification on 12/01/2025. On 12/02/2025 secondary House Manager Nancy Reyes provided all Departments of the Incident Report, and at which point included DDS Nurse Consultant.
Interview with the HM stated they were recently employed with the facility and confirmed the oversight and stated they were previously instructed to provide 24-hour notification and were unable to recall if DDS was included on the list.
The LPA determined two (2) out of three (3) Departments were appropriately notified within 24 hours, and despite the oversight, all Departments were notified of the incident in a timely manner and received a written Incident Report within two (2) days. Additionally, the violation did not present a danger or direct impact to residents in care therefore the allegation is SUBSTANTIATED and considered a TECHNICAL VIOLATION . No citation was issued.
The LPA discussed the importance of reporting requirements and ensuring compliance with all Departments to which the RD, Administrator, and HM agreed.
No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction