197603823-6-7-2022-31-AS-CHAS-CH8RGS-20220812130113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603823
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:07:51 PM

Unsubstantiated

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
06/05/2020 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20200605111033

FACILITY NAME:	NORTH LAKE VILLAS INC.		FACILITY NUMBER:	197603823
ADMINISTRATOR:	NOURIT BRAUN		FACILITY TYPE:	740
ADDRESS:	2851 N. LAKE AVE		TELEPHONE:	(626) 398-8668
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	30	CENSUS: 27	DATE:	06/07/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cynthia Martinez		TIME COMPLETED:	02:12 PM

ALLEGATION(S):

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Resident was not provided a copy of their Admissions Agreement while in care.
Facility failed to keep premises free from obstructions.

INVESTIGATION FINDINGS:

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At approximately 12:00 p.m. on 06/07/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with administrator and disclosed the reason for the visit.

Resident was not provided a copy of their Admissions Agreement while in care.
Regarding the allegation above, it was alleged the facility did not provide resident #1 (R1) with a signed copy of their admission agreement for over 4 months. To investigate, LPA Manya Lefian interviewed R1 and LPA Nicholas Reed interviewed staff #1 (S1) and staff #2 (S2) at 12:15 p.m. on 06/07/2022. LPA Lefian suggested R1 ask again for the admission agreement, and R1 confirmed it was provided. S1 informed LPA Reed that R1 already had a copy of their admission agreement. S2 told LPA Reed that R1 was provided a copy of the agreement on the day R1 moved to the facility. Based on interviews, the facility did provide the admission agreement to R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

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-20200605111033

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: NORTH LAKE VILLAS INC.	FACILITY NUMBER: 197603823
	VISIT DATE: 06/07/2022

NARRATIVE

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Facility failed to keep premises free from obstructions.

Regarding the allegation above, it was alleged that furniture belonging to a female resident blocked R1’s path to the bathroom. To investigate the allegation, LPA Lefian interviewed R1 on 06/12/2020 and LPA Reed interviewed S1 and S2 at 12:15 p.m. on 06/07/2022. S2 also toured the facility with LPA Reed at approximately 12:40 p.m. R1 told LPA Lefian that the facility “cooperated and moved her area and the table she uses so I don't have that issue anymore”. S2 explained to LPA Reed that the large chairs which blocked R1’s path were replaced with smaller chairs immediately. During the visit, LPA observed the large chairs were no longer obstructing the walkway and were moved to the side of the room. LPA observed no other obstructions. Based on interviews and observations, the facility promptly moved the obstructions from R1’s path. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations. Therefore the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

LIC9099 (FAS) - (06/04)

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