<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607123
Report Date: 03/13/2023
Date Signed: 02/03/2024 01:20:54 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
02/14/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230214165012
FACILITY NAME:ENCINO LIVINGFACILITY NUMBER:
197607123
ADMINISTRATOR:O. ALMANY & D. PETRASEKFACILITY TYPE:
740
ADDRESS:16710 MAGNOLIA BLVD.TELEPHONE:
(818) 907-1343
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:6CENSUS: 5DATE:
03/13/2023
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Maria Kristina LamsonTIME COMPLETED:
04:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff call devices are turned off
Facility is malodorous
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 ***This report amended to make a correction.***

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 1:05pm. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator later.
During initial visit, on 02/21/23, LPA Smith conducted tour of physical plant, conducted interviews with staff and requested documents relevant to the investigation.

Facility staff call devices are turned off

It was alleged that facility staff call devices are turned off. LPA interview with Administrator and staff reveal that devices are never turned off. Staff also revealed performs period checks to make ensure call devise are working. During visit on 02/21/23, LPA Smith and Staff #1 (S1) checked to ensure call devices were on in each resident room.
(Cont. to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
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 6
Control Number 31-AS-20230214165012
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: 03/13/2023
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
 ***This report amended to make a correction.***
(Cont from 9099)

The devices for each resident room were tested to ensure functionality against Staff alert control box in hallway when call device is pushed to request assistance. All devices were turned on, operable and audible alert sounded when call devices were pushed at time of visit.

Based on interviews and device check there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time

Facility is malodorous

It was alleged the facility is malodorous. Interviews with administrator revealed that they have not smelled any foul odors in the home. Interviews with five (5) out of eight (8) staff revealed have not smelled any foul odors in the facility. (S1) revealed cooks’ meals but will use air freshener spray afterwards but has not smelled any foul orders in the facility. Staff #4 (S4) and staff #5 (S5) reveal facility is cleaned and freshened during and after each shift. LPA observed staff mopping floor during visit and LPA did not detect any foul odors at time of visit.

Based on interviews and observation there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time

Exit interview conducted. A copy of the report was provided.


SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/14/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230214165012

FACILITY NAME:ENCINO LIVINGFACILITY NUMBER:
197607123
ADMINISTRATOR:O. ALMANY & D. PETRASEKFACILITY TYPE:
740
ADDRESS:16710 MAGNOLIA BLVD.TELEPHONE:
(818) 907-1343
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:6CENSUS: 5DATE:
03/13/2023
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Mia RicoTIME COMPLETED:
04:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not following Covid protocols
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 1:05pm. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was contacted and arrived later.

During initial visit, on 02/21/23, LPA Smith conducted tour of physical plant, conducted interviews with staff and requested documents relevant to the investigation.

It was alleged that staff are not adhering to Covid-19 masking protocols. Interview with staff reveal visitors are instructed to self-service area for self-temperature check and covid-19 questions on sign-in log. However, during a prior visit LPA Smith observed staff not wearing mask upon entrance to the facility. Interview with administrator and covid-19 sign in log also revealed that at least one regular staff or caregiver had not signed log to record temperature check and covid-19 follow-up questions.

(Cont. to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20230214165012
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: 03/13/2023
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)

Based on LPA observation made during prior visit, interviews, and review of sign-in log the allegation of facility not following Covid protocols protocol 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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20230214165012
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: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
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 facility. POC Date:03/17/2023
8
9
10
11
12
13
14
Based on observations made during prior visits staff ...not wearing face mask/covering while working in the facility and temperature/follow-up questions on signin log not completed which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6