197608838-6-15-2021-31-AS-MVAO-C4GNVN-20210630104812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 06/15/2021
Date Signed: 06/15/2021 11:59:28 AM

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
01/25/2021 and conducted by Evaluator Tuesday Cabiness

COMPLAINT CONTROL NUMBER: 31-AS-20210125091753

FACILITY NAME:	VILLAGE AT NORTHRIDGE, THE		FACILITY NUMBER:	197608838
ADMINISTRATOR:	BRADLEE ANN FOERSCHNER		FACILITY TYPE:	740
ADDRESS:	9222 CORBIN AVE		TELEPHONE:	(818) 350-2951
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	125	CENSUS: 90	DATE:	06/15/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Bradlee Ann Foerschner		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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1. Facility has cockroaches
2. Resident room was dirty
3. Facility has mold
4. Facility not properly storing chemicals

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Bradlee Foerschner to deliver the final findings of the allegations mentioned above. The following was determined.

Allegation # 1: Facility has cockroaches: Regarding this allegation, it was reported, that the facility has cockroaches. On February 04, 2021, from 12pm to 4pm, LPA conducted a virtual tour of several resident rooms, including resident # 1 (R1), who was named in the complaint. LPA also conducted interviews with the complainant, witnesses, and facility staff. LPA also reviewed documents and photographs pertaining to the complaint. During the virtual tour and evidence received, LPA observed R1’s room to have alive and dead roaches on the bedroom and bathroom floor, as well as in the cracks of the walls. Therefore, based on interviews, virtual tour and photographs, the allegation, “Facility has cockroaches”, is deemed SUBSTANTIATED. This poses as a potential health and safety risk to residents in care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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 31-AS-20210125091753

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: VILLAGE AT NORTHRIDGE, THE	FACILITY NUMBER: 197608838
	VISIT DATE: 06/15/2021

NARRATIVE

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Allegation # 2: Resident’s room was dirty: Regarding this allegation, it was reported, that the resident # 1 (R1)’s room was dirty. On February 04, 2021, from 12pm to 4pm, LPA conducted a virtual tour of several
resident rooms, including resident # 1 (R1), who was named in the complaint. LPA also conducted interviews with the complainant, witnesses, and facility staff. LPA also reviewed documents and photographs pertaining to the complaint. During the virtual tour and evidence received, LPA observed R1’s bedroom to have dirty floors, and soiled carpet. Bathroom also had dirty floors, dirty baseboards, and the corner and cracks of the walls were also stained and dirty. LPA also observed bathroom walls and floor to have drippings of an unknown dried substance; and underneath R1’s shower chair, to have dirt and mold. There were also spider webs were in all the windows. Therefore, based on the interviews, virtual tour and photographs, the allegation, “Resident’s room was dirty”, is deemed SUBSTANTIATED. This poses as a potential health and safety risk to residents in care.

Allegation # 3: Facility has mold: Regarding this allegation, it was reported, that the resident # 1 (R1)’s room was had mold. On February 04, 2021, from 12pm to 4pm, LPA conducted a virtual tour of several resident rooms, including resident # 1 (R1), who was named in the complaint. LPA also conducted interviews with the complainant, witnesses, and facility staff. LPA also reviewed documents and photographs pertaining to the complaint. During the virtual tour and evidence received, LPA observed R1’s bathroom to have mold in the cracks of the walls, on the floor, and underneath R1’s shower chair. Therefore, based on interviews, virtual tour and photographs, the allegation, “Facility has mold”, is deemed SUBSTANTIATED. This poses as a potential health and safety risk to resident in care.

Allegation # 4: Facility not properly storing chemicals. Regarding this allegation, it was reported, that the resident # 1 (R1) had chemicals in room, that were not properly stored. On February 04, 2021, from 12pm to 4pm, LPA conducted a virtual tour of several resident rooms, including resident # 1 (R1), who was named in the complaint. LPA also conducted interviews with the complainant, witnesses, and facility staff. LPA also reviewed documents and photographs pertaining to the complaint. Documentation and photographs received, confirmed that resident # 1 (R1) had a can of RAID and another bug repellant in R1’s bedroom. R1 had cock roaches and other bugs in room. Therefore, based on interviews, and photographs, the allegation, “Facility not properly storing chemicals” is deemed SUBSTANTIATED. This poses as an immediate health and safety risk to residents in care....................Exit interview conducted, appeal rights, and copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210125091753

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: VILLAGE AT NORTHRIDGE, THE	FACILITY NUMBER: 197608838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/21/2021 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas, shall be maintained in	1 2 3 4 5 6 7	Executive Director will provide documentation of training and follow up with housekeeping inpsection training that was completed by staff.
	8 9 10 11 12 13 14	a clean, sanitary, and odorless condition. This requirement was not met, evidenced by: based on interviews, observations and photographs, R1's room had roaches; was dirty, and mold. This is a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 06/21/2021 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met, evidenced by: based on interviews and photographs, R1 had RAID and bug repellant in room.	1 2 3 4 5 6 7	Executive Director will provide training documentation pertaining to regulations and chemicals that could be harmful to residents in care with staff
	8 9 10 11 12 13 14	This poses a potential health and safety risk to resident in care.	8 9 10 11 12 13 14

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC9099 (FAS) - (06/04)

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