197608711-11-4-2021-31-AS-EMIR-CCD2UJ-20220309164225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608711
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:54:07 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 HOME		FACILITY NUMBER:	197608711
ADMINISTRATOR:	JINA MALEKSARKISSIANS		FACILITY TYPE:	740
ADDRESS:	6720 SAINT ESTEBAN STREET		TELEPHONE:	(818) 353-3350
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	72	CENSUS: 40	DATE:	11/04/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Roy Manasan		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility having financial issues.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) PItz conducted an unannounced visit on this day 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; interviewed the administrator, four staff members, 6 memory care residents in addition to inspecting the facilities care supplies, PPE, and perishable/ non-perishable food supplies on 9/30/21 at 9:30 a.m.; conducted a telephonic interview with the administrator on 10/29/21; and conducted a visit to the facility on 11/4/21 to interview the administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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 3

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: 11/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/05/2021 Section Cited CCR 87213	1 2 3 4 5 6 7	87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records....	1 2 3 4 5 6 7	Administrator understands that the facility is being referred to an audit and has agreed to comply with all legal requests made as part of that audit process.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews the facility did not ensure that its financial plan was sufficient to maintain adequate staffing at the facility which poses an immediate risk to 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 11/04/2021

NARRATIVE

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The above allegation, that the "facility is having financial issues," has been substantiated based on the interviews conducted and observations made. On 9/24/20 the complainant informed LPA that the facility's financial hardship manifested most obviously and seriously in the form of a lack of staffing. On 9/30/21 LPA substantiated the allegation of the facility lacking staff, and on 10/01/21 LPA requested a series of financial documents by email for the purpose of referring the facility to an audit. On 10/29/21 the facility administrator informed LPA by phone that the facility's headquarters did not believe they needed to release this documentation. The allegation is therefore substantiated.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies on 9099 D page.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

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