197608838-12-15-2021-31-AS-NGID-CBWRK2-20220223120446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 12/15/2021
Date Signed: 12/15/2021 01:58:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/29/2019 and conducted by Evaluator Patrick Shanahan

COMPLAINT CONTROL NUMBER: 31-AS-20191029104349

FACILITY NAME:	VILLAGE AT NORTHRIDGE, THE		FACILITY NUMBER:	197608838
ADMINISTRATOR:	KEVAN SIDNEY		FACILITY TYPE:	740
ADDRESS:	9222 CORBIN AVE		TELEPHONE:	(818) 350-2951
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	125	CENSUS: 95	DATE:	12/15/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Helen Lee/ Assistant Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple falls and injury, due to lack of care and supervision
Facility failed to administer medication as prescribed by physician
Facility failed to observe resident's change in condition
Facility failed to report resident's change in condition to responsible party

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to complete the investigation of the above specified allegations. LPA explained the reason for the visit and was asked the COVID-19 questions before being allowed entry.

Allegation 1. Resident sustained multiple falls and injury, due to lack of care and supervision
LPA was able to speak with staff and residents regarding this allegation. LPA was also able to review all Physician Communication documents, which detailed the falls of the resident in question (R1). Although the R1 did sustain multiple falls, the falls occurred while R1 was in the presence of R1's personal caregiver or while the resident was alone in R1's apartment. Staff always responded to the falls and the facility had increased checks on the resident to hourly during the night.

Continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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-20191029104349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT NORTHRIDGE, THE	FACILITY NUMBER: 197608838
	VISIT DATE: 12/15/2021

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

According to facility documentation, R1 had a private care giver available during the hours of 7 am to 7 PM, Monday through Friday and from 7am to 3pm on the weekends. It was also discovered that on 5/13/2019, the facility reported to R1's responsible party that R1 had a change of condition and recommended physical therapy, which R1 had declined on two previous instances. Based on facility documentation and staff and resident interviews, this allegation is deemed UNSUBSTANTIATED at this time.

Allegation 2. Facility failed to administer medication as prescribed by physician
LPA was able to review R1's medication documentation in order to come to findings for this allegation. This facility uses a QuickMAR computer system in order to dispense medications to the residents. This program provides staff with a photo of the resident and the times and quantities that a specific medication will be dispensed. The LPA was able to review R1's QuickMars print out sheet, which outlined all prescribed medications and PRN medications. According to the facility documentation, all of R1's medications were given as prescribed. PRN medications were also dispensed on several occasions and were documented on the QuickMars print out.
Based on a review of R1's medical documentation, this allegation is deemed UNSUBSTANTIATED at this time.

Allegation 3. Facility failed to observe resident's change in condition
LPA was able to review the progress notes for R1 in order to come to findings for this allegation. On 11/22/2019, the LPA was able to gather progress notes of R1 beginning in April of 2016 and ending in November of 2019. The progress reports indicated that staff was aware and had been documenting and informing the responsible party regarding changes in R1's condition. The first change of condition was observed on 4/5/2017 and the responsible party was notified. More recently, a change in condition was observed on 5/13/2019 and a health and service evaluation was conducted on 5/26/2019. Another health and service evaluation was conducted on 7/4/2019 and again on 7/23/2019 as R1's condition continued to change.
Based on a review of facility documentation, this allegation is deemed UNSUBSTANTIATED.

Continues on LIC 9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20191029104349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT NORTHRIDGE, THE	FACILITY NUMBER: 197608838
	VISIT DATE: 12/15/2021

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 4. Facility failed to report resident's change in condition to responsible party
LPA was able to review facility documents in order to come to findings for this allegation. On 11/22/2019, the LPA was able to gather progress notes and health and service evaluation reports for R1 beginning in April of 2016 and ending in November of 2019. The progress reports indicated that staff was aware and had been documenting and informing the responsible party regarding changes in R1's condition. Staff indicated that when changes to a residents care plan are to take place, a health and services evaluation will be conducted. A change in condition was observed on 5/13/20/19 and a health and service evaluation was conducted on 5/26/2019. Another health and service evaluation was conducted on 7/4/2019 and again on 7/23/2019 as R1's condition continued to change. A copy of the signed and revised service plan by R1's responsible party was provided to the LPA during todays visit.
Based on a review of facility documentation, this allegation is deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3