197608838-10-3-2024-31-AS-EMIR-DABURJ-20241023154849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:50:48 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:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Thomas Rekowski- Executive Director		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mariana Agban conducted unannounced subsequent complaint visit to include additional interviews for the Substantiated complaint report on 8/15/24. LPA arrived and was greeted by the receptionist and met with Executive Director 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. During today's visit, LPA interviewed 15 out of 150 residents. The allegations remain Substantiated. POC is cleared as of 08/19/24.

Exit interview conducted and a copy of this report delivered.

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: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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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