191201168-5-20-2022-31-AS-CHAS-CEXVWA-20220531164737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191201168
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:11:33 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220518163757

FACILITY NAME:	VILLA SCALABRINI RETIREMENT CENTER		FACILITY NUMBER:	191201168
ADMINISTRATOR:	ADILSO LUIZ BALEN		FACILITY TYPE:	740
ADDRESS:	10631 VINEDALE STREET		TELEPHONE:	(818) 768-6500
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	130	CENSUS: 86	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Alicia Avila		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility has bed bugs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.
It is alleged that the facility has some issues with bed bugs. Regarding this allegation LPA conducted an interview with assistant administrator from 12:35-12:55pm. LPA also conducted an interview with residents in the facility regarding this allegation from 1:15-1:30pm. Information from interviews reveal that there was an issue with bed bugs in some rooms of the facility. Orkin Pest Control came to treat bed bugs in specific rooms on 5/13/22 and returned on 5/18/22 to finish treatment on the rooms affected with bed bugs. The Department of Public Health also came to the facility regarding bed bugs on 5/17/22. LPA also reviewed and obtained documentation from Orkin Pest Control related to their visits to the facility on 5/13/22 and 5/18/22 from 1:30-1:45pm. Based on the information obtained through interviews and documentation this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit interview conducted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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-20220518163757

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA SCALABRINI RETIREMENT CENTER	FACILITY NUMBER: 191201168
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Cleared before visit. Facility had Orkin Pest Control Company come and treat the infected areas. Copy of pest control company was obtained.
	8 9 10 11 12 13 14	Based on interviews conducted facility had an issue with bed bugs in resident rooms which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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