197608838-8-15-2024-31-AS-EMIR-DABURK-20241023154849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 08/15/2024
Date Signed: 08/15/2024 04:04:57 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
08/09/2024 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20240809162409

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: 150	DATE:	08/15/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Thomas Rekowski- Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff yelled at resident in care
Facility staff did not treat residents with dignity and respect.

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 met with Director Assisted Living and explained the reason for the visit. LPA requested copies of pertinent information which include LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and is in compliance with Title 22 Regulations.

Allegation: Facility staff yelled at resident in care
It was alleged that facility staff yelled at R1 about R1's pet. Interview with S1 denied the allegation. S1 stated that they were trying to explain the situation to R1 and their voice might have elevated from frustration. Interview with staff revealed that S1 and R1 were in the medication room where S1 was asking staff to witness R1's pet urinating in the facility hallways and on the walls. Six (6) out of 10 staff members confirmed that S1 yelled at the R1. Based on information obtained the allegation deemed Substantiated.
(Continue on 9099C)

Substantiated

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: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 3

Control Number 31-AS-20240809162409

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: 08/15/2024

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

Allegation: Facility staff did not treat residents with dignity and respect.
It was alleged that facility staff had humiliated R1 in front of others. Interview with S1 denied the allegation. S1 stated that R1 was following S1 to the medication room where S1 had asked staff to raise their hand if they had witnessed R1's pet urinating in the hallways and common areas. Interviews with six 6 out of 10 staff members confirmed that R1 was humiliated in front of staff members by arguing and looking for witnesses. Based on the information obtained the allegation deemed Substantiated.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20240809162409

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: 08/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/22/2024 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072(a)(1) Personal Rights (a)...each client shall have personal rights which include,...(1) To be accorded dignity in his/her personal relationships with staff and other persons.	1 2 3 4 5 6 7	Executive Director agreed to email LPA a statement of understanding this cited section by the POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviwes R1 was subjected to infliction of humiliation by facility staff. This poses a potential health and safety risk to the resident in	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: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3