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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201168
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:44:14 PM


Document Has Been Signed on 09/19/2024 04:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
191201168
ADMINISTRATOR:ADILSO LUIZ BALENFACILITY TYPE:
740
ADDRESS:10631 VINEDALE STREETTELEPHONE:
(818) 768-6500
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:130CENSUS: DATE:
09/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alicia Avila, Assistant AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced case management visit to this facility to address the noted deficiencies. LPA had originally arrived to conduct a required annual continuation visit. LPA met with Alicia Avila.

Based on the information obtained from the incident report that occurred at the above facility, it was concluded that LPA's review of the incident which occurred on 9/12/2024 that,

-Facility failed to submit the SIR, LIC624 for occurrence dates of 10/14/22 and 3/12/24 regarding R1's aggressive behavior towards residents.

-The facility staff intervened with R1's personal rights on 9/12/24.

All noted deficiencies were discussed with the Administrator.
Under Title 22 Division 6; Chapter 8 following citations were issued and recorded on LIC809D.
Exit interview was conducted. Copy of report was provided to the administrator.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 04:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This is not met as evidenced by;

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The Administrator will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to this regulation. The Administrator will also submit proof of training for all staff. All proof must be sent to the LPA by the POC due date.
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Facility staff intervened in R1's personal rights.
This poses a potential health and safety risk to the residents in care.
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Type B
09/26/2024
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This is not met as evidenced by,
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Licensee will fill out an incident report for the incident involving resident #1(R1) that was said to have occured on 10/14/22 and 3/12/24 and provide a statement of understanding of the cited regulation to LPA by POC due date 9/26/24.
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Facility failed to submit the SIR, LIC624 for occurrence dates of 10-14-22 and 3-12-24 regarding R1.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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