197607606-1-27-2022-31-AS-NMAN-CBQVKM-20220217153034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607606
Report Date: 01/27/2022
Date Signed: 01/27/2022 01:26:59 PM

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
09/16/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210916084541

FACILITY NAME:	NIKKEI SENIOR GARDENS		FACILITY NUMBER:	197607606
ADMINISTRATOR:	DESIREE KITAGAWA		FACILITY TYPE:	740
ADDRESS:	9221 ARLETA AVE		TELEPHONE:	(818) 899-1000
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY:	106	CENSUS: 74	DATE:	01/27/2022
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Desiree Kitagawa - Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was sexually assaulted at facility

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility and met with Executive Director Desiree Kitagawa to deliver the finding for the above allegation.

On 09/17/21, LPA conducted the initial visit. During the initial visit, LPA conducted physical plant tour at 10:05 AM, requested facility documents relevant to the investigation at 10:30 AM and interviewed staff and residents between 10:40 AM to 1:30 AM.

It was alleged that three (3) men assaulted Resident #1 (R1) at the facility.

Prior to LPA’s initial visit, the same allegation was lodged by R1 and was self reported by the facility. LPA Spaeth conducted a case management visit on 08/31/21. During this visit, LPA Spaeth’s interview with the Executive Director revealed that the facility reported the alleged sexual assault incident to the proper authorities including law enforcement but did not yield substantiation of the allegation. (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: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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 31-AS-20210916084541

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: NIKKEI SENIOR GARDENS	FACILITY NUMBER: 197607606
	VISIT DATE: 01/27/2022

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

(continued from LIC 9099)

LPA’s interview with R1 on 09/17/21 at around 10:45 AM, revealed that R1 seemed to be disoriented and a little bit confused and incoherent, but denied that anyone at the facility took advantage or R1 nor any one attacked R1, staff or resident.

LPA’s record review on 09/17/21 at around 3:30 PM, also revealed that R1 has a diagnosis of dementia. Further, there was only one (1) male resident at the Memory care unit.

LPA’s interview with the Executive Director and staff also revealed that R1 had no interaction with any male resident at the facility and there was only one (1) male at the Memory Care Unit. LPA’s interview with R1’s longtime neighbor/friend on 09/17/21 at 3:35 PM also revealed that R1 had made the same allegations when R1 was still living on own apartment and even called 911 on the neighbor/friend.

Based on the information gathered during the course of the investigation, there is insufficient information to verify the allegation. 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: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2