195850182-10-20-2022-29-AS-DPEA-CLLUZN-20221128150150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850182
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:39:52 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20221014142743

FACILITY NAME:	COTTAGES AT THE COLONY OF SHERMAN OAKS #5		FACILITY NUMBER:	195850182
ADMINISTRATOR:	LEVENTER, DVORA		FACILITY TYPE:	740
ADDRESS:	5436 TYRONE AVENUE		TELEPHONE:	(818) 479-3700
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 6	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	Dvora Leventer, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff are not wearing PPE

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi arrived unannounced to conduct an initial 10-day visit. At 1:44 p.m., the LPA met with staff and explained the reason for the visit. At 1:45 p.m., the Administrator, Dvora Leventer arrived at the facility.

At 1:54 p.m., the LPA along with staff conducted a brief physical plant tour. At 1:58 p.m., the LPA conducted an interview with one (1) resident, the rest of the residents were sleeping. At 1:50 p.m., the LPA conducted an interview with the Administrator.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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 29-AS-20221014142743

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES AT THE COLONY OF SHERMAN OAKS #5	FACILITY NUMBER: 195850182
	VISIT DATE: 10/20/2022

NARRATIVE

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Regarding allegation: Staff are not wearing PPE
It was alleged that staff in the facility were not wearing proper Personal Protection Equipment (PPE) including masks while in close contact with the residents. Upon arrival to the facility, the LPA observed all three (3) staff on site wearing masks. Yet information obtained from a credible witness confirmed on 10/04/2022, a credible witness noted that Staff #1 (S1) was not wearing masks while in close proximity of residents. During the interview conducted with the Administrator on 10/20/2022, the Administrator explained that S1 was off and was leaving the facility while the credible witness was at the facility. The LPA reminded the Administrator that while staff are in the facility, they do need to be masked. The Administrator will be conducting an in-service for all the facilities under the licensee's jurisdiction. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221014142743

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES AT THE COLONY OF SHERMAN OAKS #5	FACILITY NUMBER: 195850182
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/21/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by	1 2 3 4 5 6 7	The Administrator agreed to do the following: Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 11/11/2022.
	8 9 10 11 12 13 14	Based on observations from a credible witness, the licensee did not comply with the section cited above, as S1 was not wearing face masks in the facility, which poses an immediate personal rights 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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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