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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603823
Report Date: 11/09/2022
Date Signed: 11/10/2022 06:52:37 AM

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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20221104084618
FACILITY NAME:NORTH LAKE VILLAS INC.FACILITY NUMBER:
197603823
ADMINISTRATOR:NOURIT BRAUNFACILITY TYPE:
740
ADDRESS:2851 N. LAKE AVETELEPHONE:
(626) 398-8668
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:30CENSUS: 23DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Adam Braun, Assistant AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility staff made resident wait in the cold basement of the facility before being moved out.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Assistant Administrator Adam Braun. The purpose of the visit was discussed.

It was reported that facility staff made resident wait in the cold basement of the facility before being moved out. To investigate this allegation on 11/09/2022, between 12:40pm and 1:30pm, staff interviews were initiated. Interviews revealed that R1 was taken to the bottom floor of the facility and not the basement. Staff interviewed do not know why R1 was taken to the bottom floor of the facility prior to being relocated. Between 1:30pm and 2:00pm, records were reviewed. A Welebhealth staff confirmed that they were made to wait in a cold basement prior to R1's exit of the facility.

Continue on C 9099



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
11/04/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20221104084618

FACILITY NAME:NORTH LAKE VILLAS INC.FACILITY NUMBER:
197603823
ADMINISTRATOR:NOURIT BRAUNFACILITY TYPE:
740
ADDRESS:2851 N. LAKE AVETELEPHONE:
(626) 398-8668
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:30CENSUS: 23DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Adam Braun, Assistant AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility staff was not allowing resident to be moved out of the facility without a 30 day notice.

Facility staff did not inform resident's DPOA prior to cutting resident's hair.


INVESTIGATION FINDINGS:
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This is an amended copy of the report previously issued on 11/09/2022. The signatures were not recorded.
Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Assistant Administrator Adam Braun. The purpose of the visit was discussed.

It was reported that facility staff was not allowing resident to be moved out the facility without a 30 day notice.
To investigate this allegation, on 11/09/2022 between 12:40pm and 1:30pm, staff interviews were initiated. Staff interviews revealed that neither Licensee or Assistant Administrator were aware that Resident #1 (R1) was moving out. Staff #1 (S1) was trying to follow the facilities departure policy. Between 1:30pm and 2:00pm, LPA reviewed facility records. Records revealed that a 30-day notice of relocation must be provided to the facility by the Resident's responsible party on the monthly due date prior to relocation. The Resident's responsible party did not provide a 30-day notice of relocation to the facility. Nevertheless, R1 was alllowed to leave the facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20221104084618
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: 11/09/2022
NARRATIVE
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This is an amended copy of the report previously issued on 11/09/2022. The signatures were not recorded.

Based on interviews and record review there is not sufficient information to support this allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

It was alleged that facility staff did not inform resident's DPOA prior to cutting resident's hair. To investigate this allegation on 11/09/2022, between 12:40pm and 1:30pm, staff interviews were initiated. Interviews revealed that R1's niece came to the facility on 10/17/2022 and took them to get a hair cut. On 10/20/2022 a small piece of gum got stuck to R1's hair. Staff attempted to remove it manually, but were unable to. Staff proceeded to cut the strand of hair that had gum on it. Staff did not cut all of R1's hair.

Based on interviews there is not sufficient information to support this allegation. Therefore, this allegation is deemed to be UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20221104084618
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: 11/09/2022
NARRATIVE
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This is an amended copy of the report previously issued on 11/09/2022. The signatures were not recorded.

Based on interviews and records review there is sufficient information to support this allegation. Therefore, this allegation is being SUBSTANTIATED at this time.

Deficiency cited.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20221104084618
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2022
Section Cited
CCR
87468.1(a)(5)
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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...(5) To be accorded safe, healthful, and comfortable accommodations...
This requirement was not met as evidenced by:
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The Licensee shall submit in writing to CCLD by 11/16/2022, how they will ensure that all residents in care personal rights will be respected.
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The Licensee did not ensure that the personal rights of R1 were respected. R1 was not accorded comfortable accommodations while waiting to move out of the facility.

This poses a potential health and safety risk to residents in care.
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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: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5