197608280-3-30-2022-29-AS-JAPL-CDDSMW-20220411140034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:14:22 PM

Unsubstantiated

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20211223133434

FACILITY NAME:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	MELISSA CHRISTOPHER		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 35	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Melissa Christopher		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Facility failed to have a working elevator.
Facility did not provide written notice to the resident for rate increase.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit for the above allegations. The LPA met with Administrator Melissa Christopher and explained the reason for the visit.

During the initial visit conducted on 12/28/2021, LPA’s Salia Walker and Elsie Campos conducted a brief facility tour at 10:22 a.m., interviewed administrator at 10:36 a.m., interviewed staff at 11:05 a.m., interviewed resident at 11:25 a.m. and reviewed documents at 12:20 p.m. Today, the LPA interviewed the administrator at 12:20 p.m., collected documents at 12:50 p.m. and reviewed documents at 2:15 p.m.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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-20211223133434

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 03/30/2022

NARRATIVE

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Regarding the allegation: Facility failed to have a working elevator
It was alleged that the facility elevator had not been working for two months. LPA's conducted a physical plant tour on 12/28/21 at 10:22 a.m. and observed one elevator out of order in the facility. The plant tour further revealed that this was the only elevator in the facility and access to the 2^nd floor is only via the staircase. Information obtained from interviews revealed that the facility had previous knowledge of the elevators need for repairs. Per interviews, the administrator reveled that the elevator had challenges in the past and the facility began the process of acquiring an elevator company to modernize the elevator and signed an agreement on 10/20/2021. At the time the agreement was signed the elevator was still functioning however, on 11/19/2021 the facility discovered that the elevator was inoperable. Although the elevator modernization project was due to begin in January 2022 the facility received an email from the elevator company on 12/17/21 indicating that materials wouldn’t be available for 5 to 6 weeks. The administrator received a notification that the project would commence April 4, 2022. Based on the information obtained, whereas the elevator is currently not working the facility was aware of it and was actively working to remedy it. The administrator confirmed that the residents on the 2^nd floor are able to use the stairs and any residents needing assistance can be escorted by staff. This allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211223133434

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 03/30/2022

NARRATIVE

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Regarding the allegation: Facility did not provide written notice to the resident for rate increase
The complainant was concerned that staff raised their rent without written notification. During the investigation, a record review revealed, that the facility provided a notice on 12/8/21 informing residents that the Department of Social Services had increased Social Security Income (SSI) and State Supplementary Payment (SSP) payment standards. In addition, the facility provided residents whom needed further explanation a copy of the Provider Information Notice (PIN) 21-23-CCLD, which describes the estimated SSI rate increase (Described as PIN 21-23-CCLD ESTIMATED SSI/SSP PAYMENT STANDARDS EFFECTIVE JANUARY 1, 2022). Per regulation, licensees are required to provide residents with at least a sixty (60) day notice regarding any rate increase or rate structure change. However, facilities are not required to provide a sixty (60) day notice when it pertains to SSI rate changes. Thus, the Provider Information Notice (PIN) was issued on 11/19/2021, informing licensees that the rate change would be in effect 1/1/2022. That change would be in effect under sixty (60) days. The facility is required to notify residents as soon as the licensee is notified of SSI/SSP rate changes. Record review revealed that on 12/8/2021 residents received the notice of the rate increase. Based on the information obtained, there is insufficient evidence to support the claim, that the facility did not provide written notice to the resident for rate increase. This allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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