191201168-8-23-2023-31-AS-EMIR-D2NVRB-20240221153937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191201168
Report Date: 08/23/2023
Date Signed: 08/23/2023 10:33:58 AM

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
08/18/2023 and conducted by Evaluator Christopher Alemoh

COMPLAINT CONTROL NUMBER: 31-AS-20230818152040

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: 76	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Ardy Afshar		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facilty did not prevent insect infestation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christopher Alemoh and Licensing Program Manager (LPM) Eva Miller conducted a initial investigative visit to address the allegation above. LPA and LPM met with Co-admininstrator Ardy Afshar, an entrance interview was conducted.

The allegation: Facility failed to prevent insect infestation, indicated the facility has failed to prevent an infestation of bed bugs. LPA and LPM conducted interviews with facility co-administrator, assistant administrator and 8 of 76 residents in care. Facilty files and documents including but not limited to ongoing treatments by Orkin Precision Protection and resident council minutes demonstrate that the facility has been properly proactive in taking action to eliminate a documented preexistng bedbug presence (see Complaints 31-AS-20220812151323 and 31-AS-20220518163757). On 8/22/22 a citation was issued for CCR 87303(a) and a Plan of Correction (POC) established that included regular treatment from Orkin. On 8/25/22, proof of correction was provided and the deficiency was cleared. The correction incuded an ongoing regimen of

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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-20230818152040

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: VILLA SCALABRINI RETIREMENT CENTER	FACILITY NUMBER: 191201168
	VISIT DATE: 08/23/2023

NARRATIVE

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of treatment to eliminate existing bedbugs and prevent re-infestation. This regimen is still in force as per the previous POC.

Based on the evidence that the facility is still acting as per the Plan of Correction established on 8/22/22 the LPA & LPM determined that no new deficiency was present and that the facility is doing their due diligence in maintaining the previously agreed upon Plan of Correction. The allegation that the facility has not prevented an infestation of insects is deemed Unsubstantiated at this time.

An exit interview was conducted and a copy of the licensing report provided. Assistant Administrator Alicia Avila agreed to provide CCL with a monthly update of the progress with Orkin with a follow up incident report.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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