<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 12/30/2024
Date Signed: 12/30/2024 03:19:32 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
12/13/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20241213122323
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: 158DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mary OkhataTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly address resident's multiple falls at facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted an unannounced subsequent complaint visit for the above allegation. LPAs arrived and were greeted by the receptionist and met with the Assisted Living Director and explained the reason for the visit. LPAs requested copies of pertinent information which includes LIC 500 and Resident Roster. LPAs conducted a physical plan tour to ensure the resident's health and safety were protected and in compliance with Title 22 Regulations. On today's visit, LPAs conducted additional resident and staff interviews and obtained additional documentation relevant to the investigation.
Allegation: Staff did not properly address resident's multiple falls at facility.
It was alleged that staff failed to properly address Resident#1(R1) multiple falls at the facility. Interview with Staff#1(S1) revealed that R1 is a fall risk and sustained multiple falls causing wounds and skin tears. LPAs conducted a file review and observed that R1's Service plan confirms that R1 is a fall risk and has an unsteady gait. File review also revealed that from Nov 1, 2024, to Dec 17, 2024, R1 had multiple falls at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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 4
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
12/13/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20241213122323

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: 158DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mary OkhataTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly provide medical attention to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted an unannounced subsequent complaint visit for the above allegation. LPAs arrived and were greeted by the receptionist met with the Assisted Living Director and explained the reason for the visit. LPAs requested copies of pertinent information which includes LIC 500 and Resident Roster. LPAs conducted a physical plan tour to ensure the resident's health and safety were protected and in compliance with Title 22 Regulations.

Allegation: Staff did not properly provide medical attention to resident.
It was alleged that staff failed to provide medical attention to Resident#1(R1) resulting in the right leg wound worsening and infection. Per the records review, it was confirmed that R1 was receiving medical attention from the facility staff and outside agency to address the wound. Once R1 complained about the swelling, R1 was immediately transferred to the hospital for further evaluation. In addition, interviews with 10 out of 10 residents revealed that facility staff are providing immediate attention to address residents' medical needs. Based on information obtained the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20241213122323
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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
87464(d)
1
2
3
4
5
6
7
Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal, Appraisal and providing the other basic
1
2
3
4
5
6
7
As POC, the licensee will re-assess R1 and make updates on R1's care plan to better address R1's falls. Copy of this care plan is due to the licensing agency by January 6, 2025
8
9
10
11
12
13
14
services specified below, either directly or through outside resources. This requirement was not met as evidenced by: During file review, it was revealed that R1 is a fall risk. Facility's care plan was not sufficient in addressing R1 as being a fall risk, which poses a potential threat to a resident in care.
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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20241213122323
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: 12/30/2024
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
 Furthermore, a review of R1's care plan was insufficient when addressing R1 as a fall risk. Based on the information obtained, the allegation is substantiated. Citation issued on the 9099D. Exit interview conducted, appeal rights given, copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4