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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:12:11 PM


Document Has Been Signed on 04/17/2024 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
197608694
ADMINISTRATOR:GRACE HARTNETTFACILITY TYPE:
740
ADDRESS:5450 VESPER AVETELEPHONE:
(818) 994-7900
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY:179CENSUS: 155DATE:
04/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Grace Hartnett - Executie Director TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit in regard to a self reported incident that occurred on 04/01/2024. On that date Resident # 1 (R1) was observed outside of the community by Staff #1 (S1) while driving outside of the community. S1 then informed staff at the community who then confirmed R1 was not in the community. R1 was brought back to the facility by S1 without any injuries or health concerns.

Between 01:00pm – 03:30pm, LPA conducted a physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the incident.

Interviews conducted and records review revealed that R1 walks around the community often with their private caregiver or staff, however during that time frame that R1 eloped from the facility R1's private caregiver was not with R1.  In addition, Record review revealed that R1 is unable to leave the facility unassisted, is diagnosed with dementia, and is ambulatory. Following the 04/01/2024 elopement, staff had completed a new needs and service assessment for R1 identifying the need for use of wearing a wander guard.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2024
Section Cited
CCR
87464(f)(1)(c)

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Licensee agreed to conduct an in-service training with staff to review section cited. In addition Licensee agreed to submit a letter of understanding to LPA via email by 04/18/2024 EOD.
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Based on interviews and records review, R1 is not permitted to leave the facility unassisted, and was found outside of the facility without supervision, which poses an immediate health and safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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