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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 05/24/2021
Date Signed: 05/24/2021 03:00:57 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2021 and conducted by Evaluator Aja Richardson
COMPLAINT CONTROL NUMBER: 29-AS-20210521142347
FACILITY NAME:FOUR SEASONS ASSISTED LIVING CENTER LLCFACILITY NUMBER:
197608280
ADMINISTRATOR:JOYCE ANN ALTAMIRANOFACILITY TYPE:
740
ADDRESS:12120 CHANDLER BLVDTELEPHONE:
(818) 487-0770
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91607
CAPACITY:49CENSUS: 27DATE:
05/24/2021
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ulka Sanghagi, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's room is in disrepair
Facility is not being properly maintained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Aja Richardson initiated a complaint investigation regarding the above noted allegations. At 12:45 pm,LPA met with staff Ulka Sanghagi as the Administrator was unavailable during visit. LPA explained the reason for the visit.

Allegation #1: Resident's room is in disrepair: There are concerns that Resident #1 (R1s) window screen is damaged. To investigate this allegation at 12:50 pm, LPA conducted a brief facility tour and observed the window screen in R1's room was taped to the window and there were open gaps. Based on LPA observation this allegation is Substantiated at this time.

Allegation #2: Facility is not being properly maintained. There are concerns that there is a water leak in the back staircase. During the LPA tour at 12:50 pm, LPA observed water damage in ceiling along with the ceiling potruding down.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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 3
Control Number 29-AS-20210521142347
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: 05/24/2021
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
 Based on LPA observation this allegation is Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20210521142347
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2021
Section Cited
CCR
87303(c)
1
2
3
4
5
6
7
Maintenance and Operation: (c) All window screens shall be clean and maintained in good repair.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator will have window screen fixed and submit photo to CCL by POC due date.
8
9
10
11
12
13
14
Based on LPA observation, the facility failed to maintain resident #1 window screen which poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
Type B
05/26/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator will fix ceiling by POC due date and submit photo to CCL by POC due date.
8
9
10
11
12
13
14
Based on LPA observation, failed to fix ceiling with water damage which poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3