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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608711
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:42:17 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200922155620
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: 42DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Roy ManasanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is lacking staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted an unannounced visit on this in response to the above allegation.

As part of this investigation, LPA interviewed the complainant telephonically on 9/24/20; conducted a virtual visit and 3 client interviews, 2 staff interviews, and interview of the administrator on 9/30/20; conducted a visit on 9/30/21 at 9:30 a.m. and interviewed the administrator, four staff members, 6 memory care residents, in addition to reviewing the files of all 13/13 memory care residents.

Allegation #1, that the "facility is lacking staff," has been substantiated based on the records reviewed and interviews conducted. Interviews conducted with the facility administrators on 9/30/20 and 9/30/21 confirmed that the memory care unit has one dedicated caregiver overseeing the care and supervision of residents, with the facility-wide med tech serving as a backup when able.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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 6
Control Number 31-AS-20200922155620
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
VISIT DATE: 09/30/2021
NARRATIVE
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A file review conducted on 9/30/21 revealed that there are currently 13 residents in the memory care unit, of those 13 residents: 12 have a diagnosis of dementia, 12 require assistance with dressing and bathing, 11 require assistance with toileting, 10 are non-ambulatory, 7 are incontinent, 5 experience sundowning, 4 exhibit wandering/ inappropriate/confused behavior, 3 are aggressive, 2 require continuous bed care, 2 have a history of skin breakdown, and 2 require assistance with eating.

6/6 of the staff members interviewed on 9/30/20 and 9/30/21, in addition to the complainant on 9/24/20, gave some indication that additional staff is necessary. 4/6 residents interviewed in the memory care on 9/30/21 gave some indication that additional staff is necessary.

Report reviewed, signed and delivered. Exit interview conducted, Deficiency on 9099 D page.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
09/22/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200922155620

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: 42DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Roy ManasanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility not providing adequate food service.
Facility doesn’t have adequate supplies.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted an unannounced visit on this in response to the above allegation.

As part of this investigation, LPA interviewed the complainant telephonically on 9/24/20; conducted a virtual tour of the facility's supplies and storage areas, 3 client interviews, 2 staff interviews, and an interview of the administrator on 9/30/20; conducted a visit on 9/30/21 at 9:30 a.m. and interviewed the administrator, four staff members, 6 memory care residents, in addition to inspecting the facility's PPE, cleaning supplies, perishable and non-persishable food supplies.

Allegation #1, that "facility not providing adequate food service," has been unsubstantiated based on the observations made and interviews conducted. 6/6 staff interviews conducted on 9/30/20 and 9/30/21 failed to corroborate the allegation, as did the 9 client interviews conducted between the same dates. LPA did not observe a lack of food supplies at the facility during the 9/30/20 virtual visit or the 9/30/21 in-person visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20200922155620
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
VISIT DATE: 09/30/2021
NARRATIVE
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Allegation 21, that "facility doesn’t have adequate supplies," has been unsubstantiated based on the observations made and interviews conducted. 6/6 staff interviews conducted on 9/30/20 and 9/30/21 failed to corroborate the allegation, as did the 9 client interviews conducted between the same dates. LPA did not observe a lack of PPE, cleaning, or care supplies at the facility during the 9/30/20 virtual visit or the 9/30/21 in-person visit.

Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20200922155620
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: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited
CCR
87411(a)
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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required...
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Administrator will provide a staffing plan, which includes a sample daily schedule, that demonstrates how the documented needs of the residents in memory care can be met.
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This requirement is not met as evidenced by:

Based on records reviewed and interviews conducted, the facility does ensure that the memory care unit is sufficientyl staffed which poses a potential risk to the health, safety or personal rights of 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6