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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607606
Report Date: 08/31/2021
Date Signed: 08/31/2021 01:16:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NIKKEI SENIOR GARDENSFACILITY NUMBER:
197607606
ADMINISTRATOR:DESIREE KITAGAWAFACILITY TYPE:
740
ADDRESS:9221 ARLETA AVETELEPHONE:
(818) 899-1000
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY:106CENSUS: 66DATE:
08/31/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kevin OnishiTIME COMPLETED:
12:30 PM
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
Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit regarding an incident report that was received at the CCLD Woodland Hills office on August 27, 2021. Upon entry to the facility, LPA observed the COVID signs on the front door. LPA's temperature was taken and recorded at the front entrance sign in station. LPA was greeted at 9:20 am by Associate Executive Director, Kevin Onishi. LPA stated the reason for the unannounced visit was to investigate an incident report.
It was alleged that a resident's personal rights were violated on August 27, 2021.

At 9:35 am, LPA Spaeth requested resident documentation from the Associate Executive Director and LPA interviewed the alleged victim at 9:40 am. At 9:45 am, LPA Spaeth began a tour of the facility with the Associate Executive Director and observed the public bathrooms contained wash your hands signs, hand soap, paper towels, and trash cans. The kitchen contained the required supply of canned goods, fresh vegetables, fruits, and meats. LPA Spaeth also observed two resident apartments in which the bathrooms contained grab bars and slip-resistant mats in the showers. LPA was led to the PPE storage area and observed a six month supply of PPE. LPA Spaeth did not observe any health and safety violations when touring the facility.

Further investigation is needed at this time. Exit interview conducted and copy of the report will be emailed to the Associate Executive Director.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1