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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 04/04/2025
Date Signed: 04/04/2025 01:24:59 PM

Substantiated


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
03/25/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250325133704
FACILITY NAME:VILLAGE AT NORTHRIDGE, THEFACILITY NUMBER:
197608838
ADMINISTRATOR:THOMAS REKOWSKIFACILITY TYPE:
740
ADDRESS:9222 CORBIN AVETELEPHONE:
(818) 350-2951
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:194CENSUS: 160DATE:
04/04/2025
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:THOMAS REKOWSKITIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not make resident records available to resident's authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived and was greeted by the receptionist and met with Executive Director Thomas Rekowski and explained the reason for the visit. LPA requested copies of pertinent information which includes LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations. Today's investigation consisted of interviews with 15 out of 160 residents, 1 staff members and record review.

Allegation: Staff did not make resident records available to resident's authorized representative
It was alleged that staff did not make Resident#1's (R1) records available to R1's authorized representative. Per the complainant, the written request was sent on 02/24/25, however, there was no response from facility staff until 03/25/25. Interview with Staff#1(S1) revealed that there was a delay due to technical issues. Records review revealed that S1 had received the records request from R1's authorized representative on 02/21/25. (Continue on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
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-20250325133704
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: 04/04/2025
NARRATIVE
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 Nevertheless, S1 responded to R1's authorized representative on 04/03/25. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted, citation issued, appeal rights given and copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250325133704
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
87468.2(a)(19)
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(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days..This requirement is not met as evidenced by;
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S1 will provide proof of sending requested documents by the POC date.
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Based on interviews, the S1 did not provide the requested documents promptly to authorized representative
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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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3