197607880-8-26-2024-29-AS-DPEA-D8JW5B-20240827165854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607880
Report Date: 08/26/2024
Date Signed: 08/26/2024 02:03:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2024 and conducted by Evaluator Valeria Conway

COMPLAINT CONTROL NUMBER: 29-AS-20240719154743

FACILITY NAME:	FOUNTAINVIEW AT EISENBERG VILLAGE		FACILITY NUMBER:	197607880
ADMINISTRATOR:	ADAM PENA		FACILITY TYPE:	741
ADDRESS:	6440 WILBUR AVENUE		TELEPHONE:	(818) 654-5534
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	216	CENSUS: 106	DATE:	08/26/2024
		UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Adam Pena		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff did not comply with reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Valeria Conway conducted unannounced subsequent complaint investigation for the above allegation. LPA met with Executive Director (ED), Adam Pena, and Director of Health Service, Maria Ronna Perez, and explained the reason for the visit.

During the initial complaint visit conducted on 7/25/24, LPA conducted interviews with the Executive Director and Nurse Director at 11:15 a.m. and 11:30 a.m.,. Additionally, during the visit LPA obtained resident records and other pertinent documents relevant to the investigation. On 08/16/2024, between 9:00 A.M. and 11 A.M, LPA conducted interviews and gathered other relevant documentation. On 8/16 at 9:59 a.m, LPA also interviewed Resident #1 (R1) and R1’s Responsible Parties (RPs).

Conitinues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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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Control Number 29-AS-20240719154743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
	VISIT DATE: 08/26/2024

NARRATIVE

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Continued from LIC 9099

Allegation “Staff did not comply with reporting requirements:”

The complaint alleged that the facility staff did not comply with reporting requirements as they failed to notify the residents responsible party when the resident was sent to the hospital/Emergency Room (ER). Interviews conducted and records reviewed reflected that facility staff follows their protocol for reporting requirements and notifies all parties including but not limited to residents RPs, Community Care Licensing (CCL), and Long-Term Care Ombudsman (LTCO). Moreover, interviews conducted with R1’s RPs reflected that two (2) out of the three (3) RPs are notified of anything related to R1 and it is the family’s responsibility to communicate between the RPs. LPA did not find any documentation specifying who the facility should notify or a specific order of who to contact in case of emergency. However, facility ED agreed to ensure all three (3) RPs are informed of any future incident related to R1. Based on interviews and record review, the Department does not have sufficient evidence to determine that the staff did not comply with reporting requirements. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time.

No deficiencies cited. Exit interview conducted. Copy of the report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC9099 (FAS) - (06/04)

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