197607123-3-6-2023-31-AS-MVAO-CR8SK9-20230425135622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607123
Report Date: 03/06/2023
Date Signed: 03/06/2023 04:52:39 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230224112032

FACILITY NAME:	ENCINO LIVING		FACILITY NUMBER:	197607123
ADMINISTRATOR:	O. ALMANY & D. PETRASEK		FACILITY TYPE:	740
ADDRESS:	16710 MAGNOLIA BLVD.		TELEPHONE:	(818) 907-1343
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 5	DATE:	03/06/2023
		UNANNOUNCED	TIME BEGAN:	01:54 PM
MET WITH:	Sharon Abrigo		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not adhering to Covid-19 masking protocols.
Staff are not safeguarding the confidentiality of resident's records.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced 10-day complaint visit to investigate the allegations above. Upon entrance to the facility LPA Smith observed Staff #1 without a mask. As LPA signed in S1 put on their mask. LPA disclosed the purpose of visit and went over posted mask requirements with staff and staff acknowledge understanding of requirement. Staff also revealed administrator recently left facility for other appointment/engagement. Administrator was contacted to authorized staff to sign report.

At approximately 2:07 pm, LPA Smith conducted a tour of the facility. After end of tour per request of LPA, the administrator was contacted by Staff #1 (S1) at approximately 2:21. LPA conducted a telephone interview with the administrator and interviewed available facility staff.
Staff are not adhering to Covid-19 masking protocols
It was alleged that staff are not adhering to Covid-19 masking protocols.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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 3

Control Number 31-AS-20230224112032

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: ENCINO LIVING	FACILITY NUMBER: 197607123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely Type B 03/10/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will submit a signed dated written signed statement notifying the department what steps will be taken to ensure staff are wearing masks appropriately at all times while working in the faclilty. POC Date:03/10/2023
	8 9 10 11 12 13 14	Based on observations made during the 03/06/23 complaint investigation visit staff did not comply with the section cited above by not wearing face mask/covering while working in the facility which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Request Denied: Appeal Not Submitted Timely Type B 03/10/2023 Section Cited CCR 80070(c)(1)	1 2 3 4 5 6 7	80070 (c) All information and records obtained from or regarding clients shall be confidential. (1)The licensee shall be responsible for safeguarding the confidentiality of record contents.This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will submit signed, dated written plan on how client files will be safeguarded. POC Date: 03/10/2023
	8 9 10 11 12 13 14	Based on interviews revealed that clients files were outside in backyard and not safeguarded which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230224112032

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: ENCINO LIVING	FACILITY NUMBER: 197607123
	VISIT DATE: 03/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Cont from 9099)

During initial visit LPA observed staff not wearing a mask upon entrance to the facility.

Based on LPA observation the allegation of Staff is not adhering to Covid-19 masking protocol is Substantiated at this time.

Staff are not safeguarding the confidentiality of resident's records

It was alleged Staff are not safeguarding the confidentiality of resident's records. Interview with Administrator and staff revealed that documents/files that were located in backyard under a mattress have been removed by the Licensee last week.

Based on interviews there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

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 was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3