195850193-10-20-2022-29-AS-DPEA-CLLQF5-20221128110723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850193
Report Date: 10/20/2022
Date Signed: 10/20/2022 01:20:50 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-20221014153934

FACILITY NAME:	COTTAGES AT THE COLONY OF SHERMAN OAKS #2		FACILITY NUMBER:	195850193
ADMINISTRATOR:	LEVENTER, DVORA		FACILITY TYPE:	740
ADDRESS:	5420 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:	10:53 AM
MET WITH:	Dvora Leventer, Administrator		TIME COMPLETED:	01:22 PM

ALLEGATION(S):

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Staff are not following masking protocols to prevent the spread of COVID

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi arrived unannounced to conduct an initial 10-day visit. At 10:54 a.m., the LPA met with staff and explained the reason for the visit. At 11:18 a.m., the Administrator, Dvora Leventer arrived at the facility.

At 11:08 a.m., the LPA along with staff conducted a brief physical plant tour. Between 11:10 a.m. and 11:28 a.m., the LPA conducted interviews with three (3) residents and one (1) staff. At 11:40 a.m., the LPA conducted an interview with the Administrator. At 12:00 p.m., the LPA and Licensing Program Manager (LPM) Kristin Heffernan had a telephonic conversation with the Licensee and 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-20221014153934

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 #2	FACILITY NUMBER: 195850193
	VISIT DATE: 10/20/2022

NARRATIVE

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Regarding the allegation: Staff are not following masking protocols to prevent the spread of COVID.
It was alleged that staff in the facility were not following COVID-19 health and safety protocols, including not wearing a mask or not properly wearing a mask. At the entrance of the facility, the LPA was greeted by Staff #1 (S1), whom was not wearing a mask. Staff #2 (S2) was also at the entrance of the facility and was wearing a mask. Once instructed by Staff #3 (S3), S2 put on a mask. At 11:40 a.m., the LPA conducted an interview with the Administrator. The Administrator explained that S1 is on kitchen duty today and does not have direct contact with the residents. The LPA reminded the Administrator that regardless the staff should be wearing a mask while in the facility, unless the staff is eating. At 12:00 p.m., the LPA and the LPM had a conversation with the Licensee and Administrator reminding them of the guidance of proper use of face mask with Provider Information Notices (PINs), PIN 21-38 ASC and PIN 22-15.1 ASC. Furthermore, information obtained from a credible witness confirmed on 10/04/2022, that a credible witness noted that two staff were not wearing masks while in proximity of residents. 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-20221014153934

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 #2	FACILITY NUMBER: 195850193
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	During the time of the visit, all staff were instructed to wear a mask. 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 and interviews, the Licensee did not comply with the section cited above, as staff were 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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