197608838-5-23-2024-31-AS-EMIR-D6SUD3-20240702152851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:13:00 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/17/2024 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20240517081647

FACILITY NAME:	VILLAGE AT NORTHRIDGE, THE		FACILITY NUMBER:	197608838
ADMINISTRATOR:	THOMAS REKOWSKI		FACILITY TYPE:	740
ADDRESS:	9222 CORBIN AVE		TELEPHONE:	(818) 350-2951
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	194	CENSUS: 222	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	THOMAS REKOWSKI- Executive Director		TIME COMPLETED:	01:12 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff made financial decisions on behalf of resident without proper authorization
Staff turned off resident's telephone service
Staff turned off resident's Wi-Fi service

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegations. LPA arrived and was greeted by the receptionist and requested the Administrator. The Nursing Director Represnantive greeted and assisted LPA until Executive Director arrived. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and is in compliance with Title 22 Regulations.

LPA requested copies of pertinent information which include LIC 500 and Resident Roster. Interview with Executive Director and records review revealed that R1 lives in the independent living community part of the facility and not the Assisted living section which is licensed by Community Care Licensing. The department does not have jurisdiction in the Independent Living section of the facility. LPA obtained copies of R1's Residency and Service Agreement. Based on the information LPA gathered LPA determined that the allegation is unfounded. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. (Continue on 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240517081647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT NORTHRIDGE, THE	FACILITY NUMBER: 197608838
	VISIT DATE: 05/23/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This agency has investigated the complaint alleging (Staff made financial decisions on behalf of resident without proper authorization, Staff turned off resident's telephone service, Staff turned off resident's Wi-Fi service). We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.” Exit interview conducted and copy of report delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2