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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 07/11/2022
Date Signed: 07/11/2022 10:30:28 AM

Unsubstantiated


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
07/11/2022 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220711080429
FACILITY NAME:VILLAGE AT NORTHRIDGE, THEFACILITY NUMBER:
197608838
ADMINISTRATOR:BRADLEE ANN FOERSCHNERFACILITY TYPE:
740
ADDRESS:9222 CORBIN AVETELEPHONE:
(818) 350-2951
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:125CENSUS: 78DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tyler BarnesTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility staff administrating medication without reason
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to deliver the final findings for the allegation mentioned above. LPA met with Tyler Barnes, Operation Specialist and informed him the reason of the visit. Executive Director (ED) Bradlee Foerschner, was not available at the time of the visit. The following was determined:

It was alleged "Facility staff administered medication without reason". The allegation was not mentioned but addressed in conjunction with compliant control # (31-AS-20210125150526), dated January 2021. During the investigation, on 02/03/2021, 02/04/2021, 05/27/2022, 06/13/2022, and 06/20/2022, from various time frames, between 930am to 3:00pm, LPA reviewed medical and hospice records and other facility documents, as well as conducted interviews with the complainant, facility staff and other witnesses regarding the allegation. According to the information obtained, R1 started receiving hospice services on 12/29/2020, due to terminal illness and other chronic health conditions, which were further complicated by COVID related issues. LPA reviewed medical records, and it was documented that the prescription in question, Ativan was prescribed under hospice care,
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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 2
Control Number 31-AS-20220711080429
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: 07/11/2022
NARRATIVE
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 due to R1 having shortness of breath and anxiety. Records also revealed, the medication was administered and documented according to physician and hospice orders. Based on the information obtained through interviews and record review, there is no supporting information or corroborating evidence that "Facility staff administered medication without reason", therefore, the allegation deemed UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2