197608838-3-8-2023-31-AS-RRAZ-CSDT65-20230601142630

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 03/08/2023
Date Signed: 03/08/2023 02:32:39 PM

Unfounded

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
03/01/2023 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20230301112835

FACILITY NAME:	VILLAGE AT NORTHRIDGE, THE		FACILITY NUMBER:	197608838
ADMINISTRATOR:	BRADLEE ANN FOERSCHNER		FACILITY TYPE:	740
ADDRESS:	9222 CORBIN AVE		TELEPHONE:	(818) 350-2951
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	194	CENSUS: 114	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Maryrose Okahata		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not address a resident's change in medical condition

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that Resident 1 (R1) has a large wound on the groin. There were orders for the nurse to change R1's bandage on a regular basis, but nurse failed to change R1's bandage, which has caused R1's wound to get worse. LPAs met with the Director of the Assisted Living, Maryrose Okahata, and advised her of the allegation. Today's investigation consisted of interviews with Mary Rose, interviews with staff, and record review.

According to Maryrose, R1 has not been at the facility since January 19, 2023. R1 went to Holy Cross Hospital for a scheduled vascular surgery. From the hospital, R1 was transferred to Garden Rehab on February 2, 2023 for recovery and rehabilitation. Maryrose stated, on or around March 6, 2023, she received a call from R1's family, advising her that during R1's stay at the rehab, the nurse there has not been monitoring R1's wound, which resulted in an infection. As a result, R1 was sent back to the hospital,

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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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Control Number 31-AS-20230301112835

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: 03/08/2023

NARRATIVE

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for treatment to help R1's wound with the healing. During the day's investigation at the facility, LPA's made contact with R1's family, who confirmed that R1's infection did not occur at the facility, but at the Rehabilitation Center.

In addition to interviews, LPAs made a record review to confirm that R1 went to the hospital for a scheduled vascular surgery on January 19, 2023. R1 was set to return on Monday, March 13, 2023, but that is now pending due to the additional treatment that R1 now needs.

Based on the information obtained through interviews and record review, there was insufficient evidence to corroborate the allegation of Staff not addressing the resident's change in medical condition. Therefore, the allegation is deemed Unsubstantiated at this time. The Director of Assisted Living was advised and a copy of this report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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