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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603849
Report Date: 07/31/2024
Date Signed: 07/31/2024 12:32:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/23/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240723095720
FACILITY NAME:MANOR CARE FACILITYFACILITY NUMBER:
197603849
ADMINISTRATOR:SOMERA, ERLINAFACILITY TYPE:
740
ADDRESS:7768 ALLOTT AVE.TELEPHONE:
(818) 785-7047
CITY:VAN NUYSSTATE: CAZIP CODE:
91402
CAPACITY:4CENSUS: 3DATE:
07/31/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erlina SomeraTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Licensee does not ensure staff are properly trained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. The LPA met with administrator Erlina Somera and was explained the reason for the visit. During today's inspection, between 10:00 a.m. and 12:30 p.m., the LPA briefly toured the facility with the administrator, interviewed the Administrator, conducted a file review, and obtained copies of pertinent documents relevant to the investigation.

On the allegation that the Licensee does not ensure staff are properly trained; it is the concern of the reporting party that the administrator doesn't really train staff and just provides paper work. File review revealed that staff #1 (S1) is missing 4 hours of Postural supports, restricted health conditions, and hospice required training, in addition to 6 hours of hands-on training. Based on the information obtained, the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
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 2
Control Number 29-AS-20240723095720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR CARE FACILITY
FACILITY NUMBER: 197603849
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2024
Section Cited
CCR
87411(c)
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87411(c) Personnel Requirements. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625…
This requirement was not met as evidenced by:
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Administrator agrees to have S1 fully trained and submit proof to CCL by 08/14/2024.
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Based on record review, the licensee did not comply with the section cited above when S1 did not have 4 hours of training in postural supports, restricted health conditions, hospice, and 6 hrs of hands on training which posed 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC9099 (FAS) - (06/04)
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