197608982-3-1-2021-29-AS-KHEN-BZNTB7-20210401143438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608982
Report Date: 03/01/2021
Date Signed: 03/01/2021 02:23:59 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210224143245

FACILITY NAME:	WALNUT GARDEN VALLEY VILLAGE		FACILITY NUMBER:	197608982
ADMINISTRATOR:	BUDNERO, MAIA DR		FACILITY TYPE:	740
ADDRESS:	12823 COLLINS STREET		TELEPHONE:	(818) 358-2033
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	03/01/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Izhak Illouz - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not safeguard resident’s personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically at 12:30pm with Izhak Illouz, the facility administrator.

Between 1pm - 01:30pm LPA conducted telephone interviews with the administrator and a video call which consisted of a review of physical plant. LPA also requested copies of Census, Staff schedule, admission agreement and resident documentation relevant to the investigation, to be emailed to the LPA by end of business day today.

Regarding allegation that Staff did not safeguard resident's personal belongings, at 1:15pm, LPA interview with Resident 1 (R1) revealed that R1 received See's Chocolate candy for their birthday from their son and daughter. R1 stated that they ate all of the candy as R1 recalled eating about 2 - 3 pieces of candy a day.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

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 29-AS-20210224143245

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 03/01/2021

NARRATIVE

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Continued from 9099

LPA interview with R1 also revealed that R1 can't recall any article of clothing getting damaged by staff. LPA asked if they had any article of clothing shrink or no longer fit and R1 stated no. LPA interview with Staff 1 (S1) revealed that R1 typically eats 2 - 3 pieces of candy right after dinner. S1 has never witnessed other staff eat candy from R1 nor has S1 witnessed R1 offer their candy to staff. S1 has also never witnessed R1 inform anyone of damaged clothing. Based on information gathered during this visit this allegation has been unsubstantiated at this time.

A telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

LIC9099 (FAS) - (06/04)

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