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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608711
Report Date: 04/13/2023
Date Signed: 04/13/2023 01:32:58 PM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20230405154129
FACILITY NAME:FOOTHILL RETIREMENT CARE HOMEFACILITY NUMBER:
197608711
ADMINISTRATOR:JINA MALEKSARKISSIANSFACILITY TYPE:
740
ADDRESS:6720 SAINT ESTEBAN STREETTELEPHONE:
(818) 353-3350
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:72CENSUS: 41DATE:
04/13/2023
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Jecery Ninonuevo - AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff failed to provide resident's records to an authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gary Tan and Mariana Agban conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with administrator Jecery Ninonuevo and explained the reason for the visit.

LPAs conducted physical plant tour at 10:02 AM, requested copies of facility documents relevant to the investigation at 10:25 AM and interviewed the administrator and staff between 10:43 AM to 12:00 PM. It was alleged that the reporting party (RP) as a representative of Resident #1 (R1) made a formal request at the facility on 03/23/23 to release all of R1's records to them. Formal request was made and sent via FED EX overnight on 03/24/23 at 4:30 PM. LPAs' interview with the administrator today at 10:43 AM revealed that based on her conversation with their corporate office, they have not yet sent the requested documents to the requesting party at this time. Based on the information gathered during this visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed. Exit interview conducted. Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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 2
Control Number 31-AS-20230405154129
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOOTHILL RETIREMENT CARE HOME
FACILITY NUMBER: 197608711
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
87506(c)(1)
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1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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Administrator agreed to send the requested records and submit proof of mail to CCL on or before the POC date.
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This requirement is not met as evidenced by:

Based on LPAs interview with the administrator, licensee ensure to provide R1's record to R1's authorized representative, this poses a potential personal rights risk to the 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2