197607606-4-23-2024-31-AS-TAGD-D4TSDT-20240430134741

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607606
Report Date: 04/23/2024
Date Signed: 04/23/2024 01:52:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
04/19/2024 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240419102003

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: 70	DATE:	04/23/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Erika Riva		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit and met with Business Office Director Erika Rivas, who was informed the reason of the visit. The following information was provided during the complaint investigation:

During today’s visit, from 945am to 1pm, LPA conducted interviews and obtained and reviewed resident records. It was alleged staff did not seek medical attention for resident #1 (R1). It was revealed to LPA, that R1 recently developed a cough, that did not heal. R1’s family representative, home health agency, and primary physician was notified, and prescriptions were ordered for R1. Although it was reported, facility staff did not seek medical attention for R1, it was reported to LPA, that R1 was treated for the cough, and a chest x-ray was performed to ensure there were no further medical issues. Therefore, based on interviews, LPA does not have sufficient evidence to prove the allegation, and it’s deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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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