197608694-8-9-2021-29-AS-JAPL-C6HUXR-20210903155846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 08/09/2021
Date Signed: 08/09/2021 05:41:42 PM

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
06/16/2020 and conducted by Evaluator Salia Walker

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: 70	DATE:	08/09/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Michele Johnson, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility has not promptly provided resident's records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Salia Walker conducted a subsequent Complaint Visit to issue a change in the findings of the previously issued report which was issued on 6/19/2020. Upon arrival, LPA Walker met with Michele Johnson Executive Director and explained the reason for the visit.

Per the allegation, the facility personnel failed to provide copies of resident #1's (R1's) facility records to an authorized recipient within the required two (2) business days. The methods of request to the Assisted Living Director were in the form of Voicemail messages left on 5/19/20, 5/21/20, 6/3/20, 6/11/20 and a Facsimile transmission (Fax) sent on 5/27/20.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

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 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 08/09/2021

NARRATIVE

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On 6/19/2020 at 11:00 a.m., LPA Eva Miller conducted an initial complaint visit with the use of FaceTime during which interviews with the Administrator, Jeff LaBelle and Assisted Living Director, Sondra Albarron were conducted. Both denied knowledge or receipt of a faxed request for records or any voicemail messages from the requestor. Though the complainant had provided a Fax receipt indicating the transmission was completed, the LPA was unable to confirm that the intended recipient either received or was notified of the receipt of the fax requesting the documents 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 he would contact the requestor and resolve the issue by providing the requested documents on this date (6/19/20). The LPA determined at that time that the allegation was unsubstantiated due to insufficient evidence to either confirm or deny that the facility personnel had refused or willfully failed to promptly provide requested documents to a person or persons authorized to make such a request. This finding was delivered in the form of an LIC 9099 licensing report to the Administrator.

Despite the Administrator’s agreement during the initial complaint visit on 6/19/2020 to comply with the request for records, on or about 6/22/2020, it was brought to the attention of the LPA Eva Miller that the Administrator had not, in fact, complied with the request. Based on the discovery of this additional information subsequent to the delivery of a finding of Unsubstantiated, the LPA is amending the original finding to that of Substantiated. LPA Miller had determined that the records requested of the facility, pursuant to Health and Safety Code Section 1569.269(a)(21), were not provided within the required time frame of two (2) business days.

On this date, a citation was issued including appeal rights and a copy of the Licensing Report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

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, 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: 08/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/09/2021 Section Cited HSC 1569.269(a)(21)HSC	1 2 3 4 5 6 7	1569.269(a)(21) HSC: Enumerated rights; severability. (a) Residents of residential care facilities for the elderly.. (21) To have prompt access to review all of their records.. records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by.	1 2 3 4 5 6 7	The complaintant stated they received all requested documents on or about 07/02/2020. Therefore, POC was cleared initially on date complainant notified LPA which was 07/02/2020.
	8 9 10 11 12 13 14	Based on a statement of confirmation by Administrator LaBelle on or about 6/22/20 the facility failed to promptly produce requested records resulting in a potential risk to the personal rights of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

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