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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608838
Report Date: 09/11/2024
Date Signed: 09/11/2024 09:43:25 PM

Unsubstantiated


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
09/05/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20240905092917
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: 153DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary Okahata TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility not clean, safe, sanitary and in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived and was greeted by the receptionist and met with Assisted Living Director and explained the reason for the visit. LPA requested copies of pertinent information which includes LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations.

Allegation: Facility not clean, safe, sanitary and in good repair
It was alleged that the facility has mold and leak issues in different areas, including residents' rooms on the third floor, the basement ceiling, Staff break room, and staff restrooms. LPA toured residents rooms on the third and second floors and observed no mold or leak issues. LPA also toured the basement, staff breakroom, and restrooms and observed no leak or mold issues. LPA interviewed the Assisted Living Director and 10 staff members and 15 out of 153 residents. Interview with residents and 9 out of 11 staff members denied the allegation. (continue on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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 2
Control Number 31-AS-20240905092917
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: 09/11/2024
NARRATIVE
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Interview with the Assistant living Director revealed that when staff or residents notice any disrepair in the facility a maintenance work order will be placed immediately and maintenance staff will work on the issue promptly. Based on observations and interviews the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2