197608280-7-27-2022-29-AS-JAPL-CHEMAR-20220818092642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:32:11 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
07/20/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220720134605

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: 37	DATE:	07/27/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Clarizze Punit		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility elevator is in disrepair
Resident's medical device is inaccessible

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for an initial complaint visit for the above allegations. The LPA met with Administrator Clarizze Punit and explained the reason for the visit.

During today's visit, the LPA conducted a brief facility tour at 10:40 a.m., interviewed administrator at 11:00 a.m., interviewed residents at 11:10 a.m., 2:35 p.m. and 2:37 p.m. interviewed staff at 12:20 p.m. and 2:05 p.m. and reviewed documents at 2:30 p.m.

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: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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-20220720134605

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: 07/27/2022

NARRATIVE

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Regarding the allegation: Facility elevator is in disrepair
It was alleged that the facility elevator had not worked since September 2021. The LPA conducted a physical plant tour on 7/27/22 at 10:40 a.m. and observed one elevator in the facility that gives access to the 2^nd floor. The facility also has a staircase with access to the 2^nd floor. The LPA observed and used the elevator and confirmed that the elevator was functioning appropriately at the time of the visit. As previously addressed in Complaint # 29-AS-20211223133434, information obtained from interviews at the time revealed that the facility had previously been actively working on repairing the elevator that had not been operable since 11/19/2021. The administrator reveled at time 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. 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 elevator modernization was completed, and the elevator was fully functional effective 7/18/2022. Interviews conducted today revealed that communication regarding the working elevator was not received by all residents on the day it was working again but that as of 7/26/22 those who had not known were advised. Based on the information obtained, whereas the elevator had not been working, the facility elevator was restored to fully working order as of 7/18/2022 and all residents have been notified. 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: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220720134605

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: 07/27/2022

NARRATIVE

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Regarding the allegation: Resident’s medical device is inaccessible
It was alleged that a power chair had been delivered to the facility however it was left on the 1^st floor. The LPA conducted interviews with Staff #1 (S1) and resident #1 (R1) which confirmed that a power chair had been delivered weighing about 200 lbs in April 2022. The facility was undergoing an elevator modernization at the time which resulted in the chair having to be left downstairs as it was too heavy to lift. S1 communicated to the resident that the chair would be temporarily stored in a room on the 1^st floor, to which R1 agreed as it was confirmed that R1 was able to use the power chair at their request when needed. It was additionally communicated that R1 personally ordered this power chair for their own personal use. A review of documentation further revealed that R1 was able to ambulate with a walker or a wheelchair and could utilize the power chair on the 1^st floor if needed. Absent of this power chair resident could still ambulate with a walker or a wheelchair. It is noted that the facility is cleared for ambulatory only on the 2^nd floor and based on the fact that resident ambulates with a walker R1 was relocated to the 1^st floor, mid May 2022. Based on interviews which were conducted, there is insufficient evidence to support the allegation that the resident’s medical device is inaccessible. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is 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: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC9099 (FAS) - (06/04)

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