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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 10:21:09 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
01/25/2021 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210125150526
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:
09:30 AM
MET WITH:Tyler BarnesTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained a pressure injury while in care
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 that resident #1 (R1) sustained a pressure injury while in care at the facility. 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. While under hospice care, R1’s health began to decline, and R1 became incontinent, and developed a skin tear on R1’s buttock. Interviews and documentation revealed that facility staff and hospice nurses had knowledge that R1 developed
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-20210125150526
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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a skin tear and treatment was provided to R1 as needed by hospice nurses and facility staff. Further review of R1’s medical records revealed that although R1’s hospice care plan was not updated to indicate R1’s skin condition/pressure injury, hospice nurses and facility staff were assisting R1 by turning, repositioning, and providing treatment for the skin tear. Overall, the investigation revealed that although R1 developed a skin tear while in the facility, there is no supporting information or corroborating evidence that R1 developed a skin condition due to neglect and care and supervision by facility staff, 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