191201168-8-22-2022-31-AS-RRAZ-CJ77K4-20220911214318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191201168
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:11:13 AM

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
08/12/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220812151323

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: 85	DATE:	08/22/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Alicia Avila		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident's room 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 the facility staff and explained the reason for this visit.
A physical plant tour was done from 10-10:10am to ensure no immediate health and safety issues were present and none were noted during the tour
It is alleged that resident # 1 (R1) room has had bed bugs. LPA conducted an interview with the administrator regarding this allegation from 10:10-10:20am. LPA conducted an interview with R1 regarding this allegation from 10:20-10:30am. Information from interviews reveal that R1 has had continuous issues with bed bugs in their room. Orkin pest control came out to treat R1's room on 8/16/22, 8/17/22, and 8/18/22. R1's room did have live bed bugs and a deep cleaning was done and furniture that had bed bugs was thrown away and replaced. LPA also received documentation of past treatments that has been done by Orkin in not only R1's room but throughout the facility. Based on the information obtained this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Civil penalty of 250 dollars is issued for a repeat violation of the same citation which was issued on 5/20/22. Exit Interview conducted, Appeal Rights explained. Copy of report issued.

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: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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-20220812151323

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: 08/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/22/2022 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	Corrected before visit. Facility had Orkin Pest Control company come out three times last week to treat the facility for bed bugs and a deep cleaning was done.
	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: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC9099 (FAS) - (06/04)

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