197608694-5-26-2023-29-AS-DPEA-CU9TXM-20230731150721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 05/26/2023
Date Signed: 05/26/2023 01:37:15 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
01/26/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20230126135804

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: 150	DATE:	05/26/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Keith Payne		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility lacks adequate staffing to meet residents care needs

Facility staff speak inappropriately to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the allegatioSn listed above. LPA met with Executive Director Keith Payne and explained the reason for the visit.

On 01/27/2023, between 2:30pm - 4pm, LPA conducted physical plant, interviewed (7) staff and reviewed and obtained pertinent documents relevant to the investigation. On 03/28/2023, LPA interviewed (10) residents during a subsequent visit for a separate investigation. Today LPA conducted physical plant and reviewed pertinent documentation relevant to the investigation.

It was reported that facility lacks adequate staffing to meet residents care needs as it was alleged that the facility is short staffed and there is only one caregiver most nights. Records review revealed at least (2) caregivers are scheduled during the NOC shift.

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: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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-20230126135804

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: 05/26/2023

NARRATIVE

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Continued from 9099

LPA's interview with ten (10) residents revealed that eight (8) out of the ten (10) residents interviewed did not express any immediate or potential concerns for staff being unable to meet their needs due to lack of staffing. Two (2) of the ten (10) who did share some dissatisfaction stated their concerns from when they were first admitted and that staffing and care has improved since then. Additionally LPA's interview with Director of Assisted Living Ada Navarette revealed , whenever they experience call outs , shifts are either covered by themselves, management, Med Techs, or as a last resort, any staff who are able to pick up extra shifts. They also are in contact with outside agencies to cover shifts if the need were to arise. Interviews with six (6) staff revealed when call outs occur, other staff who are available to work were asked to cover if the Assisted Living Director or Med techs were not able to cover. Additionally the staff interviewed stated they do not recall a significant amount of call outs at this time. Based on interviews conducted and records reviewed, the department does not have sufficient evidence to determine that facility lacks adequate staffing to meet residents care needs. Therefore, the above allegation has been deemed UNSUBSTANTIATED at this time.

It was alleged that facility staff speak inappropriately to Resident 1(R1), LPA's interview with ten (10) residents, six (6) staff and (3) private caregivers revealed that each have never witnessed any staff speak inappropriately to any resident at this time. Based on interviews conducted, the department does not have sufficient evidence to determine that facility staff speak inappropriately to R1 or any other residents in care at this time. Therefore, the above allegation has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

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