197608694-6-19-2020-29-AS-JAPL-C6HUXS-20210903155846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 06/19/2020
Date Signed: 06/19/2020 12:10:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2020 and conducted by Evaluator Eva Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200616132824

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	JEFF LABELLE		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	100	CENSUS: 60	DATE:	06/19/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jeff LaBelle		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility has not promptly provided resident's records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Eva Miller initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually with the use of "FaceTime" with Administrator Jeff LaBelle and Director of Assisted Living, Sondra Albarron.

Per the allegation the facility personnel failed to promptly provide requested records. The methods of request to the Assisted Living Director were in the form of Voicemail messages and a Facsimile transmission (Fax) . LPA conducted an interview with the Administrator and Assisted Living Director. Both denied knowledge or receipt of a faxed request for records or any voicemail messages from the requestor.

Though the complainant provided a Fax receipt indicating the transmission was completed the LPA was unable to confirm that the intended recipent was either notified of the receipt of the fax, or provided the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020

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-20200616132824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 06/19/2020

NARRATIVE

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document(s) in question. The LPA was unable to confirm that any voicemail messages were successfully recorded or received by the Assisted Living Director. The Administrator advised that he would contact the requestor on this date and resolve the issue and provide the requested documents promptly.

At this time the allegation is unsubstantiated due to insufficient evidence to either confirm or deny that the facility personnel willfully failed to promptly provide requested documents to a person or persons authorized to make such a request. The Administrator assured the LPA that the requestor will be contacted and the documents will be provided appropriately as per CA Health and Safety Code Section 1569.269(a)(21) and that Community Care Licensing will be notified upon completion.

A copy of this licensing report was scanned and emailed to the Administrator for Signature and return on this date.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020

LIC9099 (FAS) - (06/04)

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