197608694-5-28-2024-29-AS-DPEA-D5SPTC-20240531113542

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:36:57 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
11/01/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20231101085510

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	KEITH PAYNE		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	179	CENSUS: 155	DATE:	05/28/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Grace Hartnett - Executie Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff leaves resident soiled for an extended period of time.
Staff speak inappropriately about residents to other staff.
Staff do not properly dispose resident's diapers.
Staff do not clean soiled furniture.
Staff leaves residents unsupervised for an extended period of time.
Staff do not include resident(s) in outside activities.
Staff do not follow proper hand washing practices.
Staff do not wear protective masks when sick.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Executive Director Grace Hartnett and explained the reason for the visit.

On 11/03/2023, from 10:00 a.m. – 3:00 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed private caregivers, interviewed staff, and reviewed and obtained pertinent documents relevant to the investigation. On 04/29/2024, from 10:00 a.m. – 3:00 p.m. LPA conducted a subsequent visit and conducted physical plant and interviewed family members of residents in care. On 05/28/2024, at approx. 01:15 p.m. LPA interviewed Resident #1 (R1)’s case worker (CW).

It was reported that “Staff leaves resident soiled for an extended period of time, as it was alleged that R1 is not provided incontinent services in a timely manner.

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: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 29-AS-20231101085510

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: 05/28/2024

NARRATIVE

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Continued from 9099
Interviews conducted with six (6) private caregivers and six (6) staff, reflected that residents who require incontinent services are provided upon request and resident diapers are checked at least three (3) times per shift, once before a caregivers shift starts, again after meals and commonly before a caregiver’s shift ends. All twelve (12) parties interviewed above never observed any resident left in soiled diapers for an extended period. LPA’s interview with seven (7) family members / responsible parties of residents in care revealed they did not express any immediate or potential concerns for residents not provided incontinent services in a timely manner. LPA’s interview with R1’s Case worker further revealed they have never been informed of R1 being left in soiled clothing or diapers for an extended period. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff leaves resident soiled for an extended period of time” is deemed Unsubstantiated at this time.

It was reported that “Staff speak inappropriately about residents to other staff” as it was alleged that staff are making inappropriate comments to resident’s private caregivers. Interviews conducted with six (6) private caregivers, six (6) staff, seven (7) family members / responsible parties of residents in care and R1’s case worker revealed that the twenty (20) parties interviewed above have not witnessed any staff speak inappropriately about residents. Each party interviewed also did not express any potential or immediate concerns that staff speak inappropriately about residents in care. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff speak inappropriately about residents to other staff” is deemed Unsubstantiated at this time.

It was reported that “Staff do not properly dispose resident’s diapers”, as it was alleged that soiled diapers are not thrown away and are left around R1’s bedroom. Interviews conducted with six (6) private caregivers and six (6) staff revealed that all twelve (12) parties interviewed have not observed any soiled diapers laying around any resident’s room. In addition, the (12) parties interviewed revealed, that when a resident is provided incontinent care, staff bring a plastic bag with them so they can dispose of the soiled diaper in the plastic bag.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20231101085510

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: 05/28/2024

NARRATIVE

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Continued from 9099-C

Once the service is complete the staff dispose the plastic bag in a trash container outside of resident's room. LPA’s interview with R1’s case manager and seven (7) family members / responsible parties of residents in care revealed they did not express any potential or immediate concerns for staff not disposing soiled diapers properly. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff do not properly dispose resident’s diapers,” is deemed Unsubstantiated at this time.

It was reported that “Staff do not clean soiled furniture” , as it was alleged that a chair in R1’s room is often soiled and staff do not clean it in a timely manner. Interviews conducted with six (6) private caregivers, six (6) staff, and seven (7) family members / responsible parties of residents in care revealed that the nineteen (19) parties interviewed have never observed any piece of furniture soiled for an extended amount of time in resident bedrooms. Each party interviewed also did not express any potential or immediate concerns for any piece of furniture not being cleaned in a timely manner. In addition, LPA interview conducted with Staff #1 (S1) and R1’s case worker, revealed when a resident soils a piece of furniture it is cleaned right away by housekeeping staff. During the physical plant on 11/03/2023 and 04/29/2024, LPA observed chair in R1’s room to be clean and there was no evidence of the chair being severely soiled. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not clean soiled furniture” is deemed Unsubstantiated at this time.

It was reported that “Staff leaves residents unsupervised for an extended period of time”, as it was alleged that residents in wheelchairs are left unsupervised for extended periods of times after activities. Interviews conducted with six (6) private caregivers, six (6) staff, R1’s case worker and seven (7) family members / responsible parties of residents in care revealed that the twenty (20) parties interviewed above, have never observed any resident left unsupervised. Each party interviewed also did not express any potential or immediate concerns for any resident being left unsupervised for an extended period. During physical plant on 11/03/2023 and 04/29/2024, LPA observed residents participating in an activity and upon completion LPA did not observe any resident left unsupervised for an extended period.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20231101085510

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: 05/28/2024

NARRATIVE

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Continued from 9099-C

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff leaves residents unsupervised for an extended period of time” is deemed Unsubstantiated at this time.

It was reported that Staff do not include R1 in outside activities, as it was alleged that staff never ask R1 if they want to participate in any activities. Interviews conducted with six (6) private caregivers and seven (7) family members / responsible parties of residents in care revealed that all thirteen (13) parties did not express any potential or immediate concerns that residents were not asked to participate in activities. Interviews conducted with six (6) staff revealed that in the morning residents are presented with the activities for the day and they are asked if they want to participate. In addition, staff, R1’s case worker and the private caregiver of R1 continued to state that R1 rarely chooses to participate in any activities as they prefer not to be around loud noise or bright lights. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff leaves residents unsupervised for an extended period of time” is deemed Unsubstantiated at this time.

It was reported that “staff do not follow proper hand washing practices”, as it was alleged staff are sitting down with residents in the dining room, eating their own meals and feeding the residents without washing their hands. Interviews conducted with six (6) private caregivers, six (6) staff , and six (6) dining room staff revealed that all eighteen (18) have not observed any staff eating their own meal while assisting residents with their food. In addition, the (12) staff interviewed revealed they are required to wash their hands before and after handling food. Interviews conducted with R1’s case worker and seven (7) family members / responsible parties of residents in care revealed they did not express any potential or immediate concerns for staff not following proper hand washing practices.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20231101085510

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: 05/28/2024

NARRATIVE

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Continued from 9099-C

During physical plants on 11/03/2023 and 04/29/2024, LPA did not observe any staff eating their own meal while assisting residents with their food. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not follow proper hand washing practices” is deemed Unsubstantiated at this time.

It was reported that “Staff do not wear protective masks when sick,” as it was alleged that multiple staff members do not wear masks when showing cold like symptoms. Interviews conducted with six (6) private caregivers, six (6) staff revealed that all twelve (12) parties interviewed have not observed any staff provide service to residents while showing cold symptoms. In addition, interviews with six (6) staff revealed that when any staff shows any cold or flu like symptoms they are typically sent home for the day. Interviews conducted with R1’s case worker and seven (7) family members / responsible parties of residents in care revealed that each family member / responsible party did not express any immediate or potential concerns for staff not following proper infection control protocols. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not wear protective masks when sick” is deemed Unsubstantiated at this time.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC9099 (FAS) - (06/04)

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