197608694-7-17-2021-31-AS-NMAN-C57NYA-20210723105226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 06/18/2021
Date Signed: 07/17/2021 12:56:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2019 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20191204144635

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	BECKER, GREG		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	100	CENSUS: 62	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Elizabeth Ham - Director of Assisted Living		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff failed to follow doctor's orders

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegations. LPA met with Director for Assisted Living Elizabeth Ham and explained the reason for the visit.

LPA conducted the initial visit on 12/09/19. During the visit, LPA conducted interview with the Executive Director and staff of the facility. LPA also requested copies of pertinent documents relevant to the investigation. Regarding the allegation that Staff failed to follow doctor's orders, LPA record review on 12/09/19 revealed that all of Resident #1 (R1)'s assessment were noted to abide by doctor's order not to be provided alcohol. LPA observation during physical plant tour on 12/09/19 at 10:32 AM, also revealed that R1's information is prominently displayed in the kitchen with R1's picture not to provide R1 with alcohol per doctor's order. LPA interview with staff on 12/09/19 between 10:01 AM to 1:03 PM, also revealed that residents were only provided wine or champagne during dinner and special occasion upon request and that no one provided alcoholic beverage to R1 during meals as they are aware of the doctor's order. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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 31-AS-20191204144635

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 06/18/2021

NARRATIVE

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(continued from LIC 809)

Regarding the allegation that the Responsible Party (RP) was not appraised of the resident's services from staff, LPA record review on 12/09/19 revealed that R1 was admitted on 12/01/18 had a signed appraisal needs and services plan throughout R1's stay at the facility. Further review also revealed that the facility has no specific care records for the residents as they were not required to do so.

Regarding the allegation that staff failed to answer calls from resident in a timely manner, LPA record review on 12/09/19 and today at 12:32 PM, revealed that the alarm system has two (2) step of clearing resident pendant call 1) Upon responding to the pendant call, the care staff attending to the call has to clear the alarm on the pendant and 2) the care staff has to clear the call from their phone software program. LPA interview with staff revealed that they sometime forgot to clear their phone software program after attending to the residents. LPA interview with six (6) residents (or (10%) of current census revealed that the facility staff almost always arrive within ten (10) minutes or reasonable time depending on the time of the day.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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