<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 12/14/2021
Date Signed: 12/14/2021 02:16:53 PM

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:PAMELA MUNDAYFACILITY TYPE:
740
ADDRESS:5450 VESPER AVETELEPHONE:
(818) 994-7900
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY:100CENSUS: 61DATE:
12/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Michele JohnsonTIME COMPLETED:
01:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection pertaining to a self reported Unusual Incident/Injury Report (LIC 624) received on 12/13/2021. The LPA met with Memory Care Director Yasmin Hernandez at 11:32 AM as the Executive Director Michele Johnson was in a meeting.

The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 11/29/2021 regarding Resident #1 (R1). During today's inspection, the LPA conducted interviews with Memory Care Director Yasmin Hernandez, two facility staff, and Resident #2 (R2) between 11:47 AM and 12:42 PM. The LPA reviewed facility records and obtained copies of pertinent records.

At 1:10 PM, the LPA reviewed the video footage of the lobby area with Executive Director Michele Johnson and obtained a copy of the requested footage.

No immediate health and safety concerns were observed during today's inspection. The LPA has determined further investigation is needed. The report was reviewed with Executive Director Michele Johnson. A copy of the report will be emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1