197603823-6-7-2022-31-AS-CHAS-CHD5FJ-20220816195511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603823
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:06:26 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
05/27/2020 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20200527082812

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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Staff threatening resident with eviction.
Resident's needs are not being met.

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.

Staff threatening resident with eviction.

Regarding the allegation above, it was alleged the facility threatened to evict resident #1 (R1). To investigate the allegation, LPA Manya Lefian interviewed staff #1 (S1) at 9:49 a.m. on 06/05/2020 and LPA Reed interviewed S1 at 12:30 p.m. on 06/07/2022. LPA Reed also conducted a record review on 06/07/2022 at 12:58 p.m. S1 told LPA Lefian the facility “did not threaten [R1] with an eviction” and needed to find R1 a higher level of care due to a worsening stage 2 pressure injury. From record review, home health notes from 06/05/2020 indicated a primary diagnosis of “pressure ulcer of right buttock, stage 2” and a secondary diagnosis of “pressure ulcer of other site, stage 2”. Due to R1’s large size, S1 and S2 conducted a body scan on R1. S1 and S2 determined the wound was greater than stage 2 and called for medical transport for R1.

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-20200527082812

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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Based on interview and record review, R1 needed a higher level of care than the facility offered to treat R1’s pressure ulcers. 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.

Resident's needs are not being met.

Regarding the allegation above, it was alleged staff did not assist R1 with bathing or incontinence needs. To investigate the allegation LPA Lefian interviewed S1 at 9:49 a.m. on 06/05/2020 and LPA Reed interviewed S1 and S2 at 12:15 p.m. on 06/07/2022. S1 told LPA Lefian that the facility offered to remove R1’s excrement. The facility has also offered to bathe R1, yet R1 refused. S2 told LPA Reed the facility constructed an extra large toilet seat to accommodate R1. S1 told LPA Reed R1 always refused bathing and assistance with toileting. Based on interviews, the facility offered R1 adequate assistance with bathing and toileting. 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.

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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