197608280-6-13-2023-29-AS-DPEA-D7Q5VD-20240731201718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 06/13/2023
Date Signed: 06/13/2023 04:14:42 PM

Substantiated

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
06/08/2023 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20230608083803

FACILITY NAME:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	CLARIZZE PUNIT		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 35	DATE:	06/13/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ulka Sawghavi		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility has bed bugs/roaches

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an initial complaint visit to the above facility. LPA Ascencio met with Staff Member Ulka Sawghavi at 1:00 p.m. Entrance interview conducted. Administrator Clarizze Punit was not available as Administrator is on leave.

On 06/08/2023, the Department received a complaint alleging that the facility has bed bugs/roaches. On 06/13/2023, LPA Ascencio conducted interview with Staff #1 (S1) at 1:00 p.m. Interview with S1 revealed that a fumigation company comes in once a week for routine pest control. The pest control company ask if we have any active bed bug cases or cockroaches, but we haven’t had any in a while. Later that same day, interviews with five (5) residents, starting at 1:20 p.m. revealed that residents have not seen or had bed bugs in their room, but they have seen cockroaches. Interviews stated the cockroaches come and go but every now and then, they are seen in the hallway, on their wall, or in their dresser.
Continued on LIC 9099 - C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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-20230608083803

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: 06/13/2023

NARRATIVE

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Interview with Resident #1 (R1), beginning at 01:37 p.m. revealed that the top drawer in their room is infested with roaches. Additionally, R1 mentioned there was an incident where a cockroach was crawling on R1 while asleep. During R1 interview, LPA Ascencio received permission from R1 to open top drawer of R1’s dresser. LPA Ascencio observed one (1) cockroach in the corner of the drawer. Upon moving a folder paper in the drawer, an additional 4 – 7 cockroaches were observed. That same day, interview with Maintenance Director (MD) at 2:15 p.m. revealed a pest company come in two (2) times a month to fumigate the facility. When we find any pest activity, the pest company comes in and fumigates the room and the following two (2) adjacent rooms to stop the spread. I made the pest company aware of pest activity that LPA found and will have them treat the rooms the next day.

Thus, based on observation and interviews, the allegation of the facility has bed bugs/roaches is deemed substantiated at this time.

1 citation was issued during today’s visit. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted and copy of the report and appeal rights provided to Staff Ulka.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230608083803

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: 06/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/23/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operations (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 is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will have outside company fumigate the entire building and target specific rooms were interviews were conducted. Administrator will submit invoice of fumigation to CCL by 06/23/2023.
	8 9 10 11 12 13 14	Based on interviews and observation, the licensee did not comply with the section above as various resident stated observing cockroaches additionally the LPA observed cockroaches in a R1's room which poses an potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC9099 (FAS) - (06/04)

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