197607256-8-16-2021-31-AS-NMAN-C6B2BU-20210827171544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607256
Report Date: 08/14/2021
Date Signed: 08/16/2021 10:04:47 AM

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
03/04/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210304161117

FACILITY NAME:	GLORIA'S CARE VILLA		FACILITY NUMBER:	197607256
ADMINISTRATOR:	ALBERT SALUNGA		FACILITY TYPE:	740
ADDRESS:	11328 WOODLEY AVENUE		TELEPHONE:	(818) 832-2020
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	0	CENSUS: 0	DATE:	08/14/2021
		UNANNOUNCED	TIME BEGAN:	07:57 AM
MET WITH:	Gloria Santos - Administrator		TIME COMPLETED:	10:28 AM

ALLEGATION(S):

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Facility took financial advantage of resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to deliver the final findings of the above allegation. LPA met with former licensee and administrator Gloria Santos and explained the reason for the visit.

This facility closed on 04/12/2021 and went through a change of ownership. LPA conducted the initial visit virtually on 03/09/2021. During the course of the investigation, LPA interviewed the licensee, administrator and friend of Resident #1 (R1) on 03/09/21 between 9:30 AM to 12:00 noon. LPA also obtained facility records on 03/09/21 and Skilled Nursing Facility (SNF) records where R1 used to live on 04/22/21 and attempted to interview Primary Care Physician (PCP) and interviewed former facility staff on 04/07/21. LPA also consulted with the Audit Section of the Department on 08/02/21.

LPA facility record review revealed that R1 was admitted on 05/23/2019 and was admitted on Hospice Care on 05/29/19. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2021

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-20210304161117

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: GLORIA'S CARE VILLA	FACILITY NUMBER: 197607256
	VISIT DATE: 08/14/2021

NARRATIVE

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(continued from LIC 9099-C)

Due to R1's declining health and medical condition, R1 was hospitalized on 06/24/19 and was discharged to a SNF on 07/03/19 where R1 eventually passed. R1's belongings was removed at the facility by R1's friends on 07/08/19.

LPA's record review revealed that R1 was self responsible during the time of admission and throughout R1's stay at the facility. R1 signed owned admission agreement and even own Hospice Services own admission agreement. Further review also revealed that R1 was able to manage own cash resources. Moreover, review of R1's medical record from the SNF also revealed that R1 was alert and oriented and no indication of any mental issues and there was no history of psychiatric hospitalization nor R1 was taking any psychotropic medication. Furthermore, LPA's interview with R1's friend on 03/09/21 also revealed that R1 was of sound mind and could make own decision for everything. LPA's interview with former staff of the facility who took care of R1 during R1's stay also confirmed that R1 was aware and sharp at the time R1 was at the facility.

Based on the information gathered during the course of the investigation, it is concluded that the facility did not financially take advantage of R1 and the facility provided the services paid for by R1 based on the admission agreement signed by R1. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2021

LIC9099 (FAS) - (06/04)

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