197608694-8-22-2023-29-AS-DPEA-CX5QF4-20231031120719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 08/22/2023
Date Signed: 08/22/2023 04:09:27 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
11/01/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20221101102804

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	DANA ANDERSON		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	179	CENSUS: 155	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Ada Navarette - Director of Assisted Living		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not follow COVID protocol

Staff do not distribute medications as prescribed

Staff did not assist residents with bathing

Staff did not provide residents with linen

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the allegations listed above. LPA met with Ada Navarette - Director of Assisted Living and explained the reason for the visit.

On 11/07/2022, between 12:45PM - 02:15PM, LPA initiated the complaint visit and conducted physical plant, interviewed staff and reviewed and obtained pertinent documents relevant to the investigation. On 01/28/2023, LPA interviewed seven (7) staff and three (3) private caregivers during a subsequent visit for a separate investigation. On 05/26/2023, between 12:30 - 3pm, LPA conducted subsequent visit and toured the physical plant and LPA interviewed (10) residents. Today LPA conducted physical plant interviewed staff and residents as well as obtained and reviewed additional pertinent documentation relevant to the investigation.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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-20221101102804

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 08/22/2023

NARRATIVE

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Continued from 9099

It was reported that staff do not follow COVID protocol as it was alleged that doors were left open for residents who had tested positive for COVID-19. Interviews with ten (10) residents, seven (7) staff and three (3) private caregivers revealed that each have never observed doors left open for any resident when there was a COVID-19 outbreak in the community. All persons interviewed did not express any immediate or potential concerns for any staff to not follow COVID-19 protocols. Based on information gathered during the investigation , the department does not have sufficient evidence to determine the above allegation occurred. Therefore the allegation that staff do not follow COVID protocol has been deemed Unsubstantiated at this time.

It was reported that Staff do not distribute medications as prescribed as it was alleged that on 10/22/2022 and 10/29/2022, there were no supervisors, which resulted in residents receiving their medications late as well as causing Resident #1 (R1) to miss a dose of insulin. Interviews conducted and records reviewed revealed although the Executive Director was not present in the community on those dates, adequately trained personnel and senior staff were on the premises. The Executive Director and Director of Assisted Living were immediately available by phone. Interviews conducted with ten (10) residents revealed that ten (10) out of ten (10) residents interviewed do not recall receiving their medications excessively late during any weekends. Each resident interviewed did not express immediate or potential concerns for experiencing delays in receiving their medication during any day of the week. Records review of (5) randomly chosen Medication Administration Records (MAR) revealed that each resident was administered their medication as prescribed. It was also reported that R1 was not administered Insulin on 10/30/2022. Records review of the MAR of R1 revealed R1 was out of the facility on 10/30/2022. Based on information gathered during the investigation, the department does not have sufficient evidence to determine the above allegation occurred. Therefore the allegation, that staff do not distribute medications as prescribed has been deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221101102804

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 08/22/2023

NARRATIVE

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Continued from 9099-C
It was reported that staff did not assist residents with bathing, as it was alleged that on 10/22/2022 and 10/29/2022 there were no supervisors, which resulted in residents not receiving their showers. Interviews conducted and records reviewed revealed although the Executive Director was not present in the community on those dates, adequately trained personnel and senior staff were on the premises. The Executive Director and Director of Assisted Living were immediately available by phone. revealed the Executive Director at the time was not scheduled on those days, the shifts were sufficiently covered by twenty-four (24) residents are scheduled for showers on Saturdays. Eight (8) out of Eight (8) residents who are scheduled for showers on Saturdays do not recall ever missing a scheduled shower on a Saturday. Two (2) out of the eight (8) reported that a few times they have experienced some delays, but showers / bathing were never missed. Based on information gathered during the investigation, the department does not have sufficient evidence to determine that this allegation occurred. Therefore the allegation that staff did not assist residents with bathing has been deemed Unsubstantiated at this time.

It was reported that staff did not provide resident with linen as it was alleged that on 10/22/2022 and 10/29/2022 there were no supervisors, which resulted in residents not receiving clean / fresh linen. Interviews conducted and records reviewed revealed although the Executive Director was not present in the community on those dates, adequately trained personnel and senior staff were on the premises. The Executive Director and Director of Assisted Living were immediately available by phone. Interviews conducted with ten (10) residents revealed that each resident receive fresh towels weekly and upon request. Sheets get washed at least once a week and upon request as well. Residents interviewed do not recall a time when they did not receive fresh towels or sheets. Records review of Weekly Assisted Living Towels Distribution log further revealed on 10/22/2022 (155) towels ( bath towels, hand towels and washcloths) were distributed to the residents and on 10/29/2022 (150) towels ( bath towels, hand towels and washcloths) were distributed to the residents. There were (83) residents in the community during those dates. Based on information gathered during the investigation, the department does not have sufficient evidence to determine that this allegation occurred. Therefore the allegation that staff did not provide resident with linen has been deemed Unsubstantiated at this time.

Exit interview conducted and a copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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