197609330-1-20-2023-29-AS-DPEA-CNKR7C-20230130114607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609330
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:52:39 PM

Substantiated

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
12/08/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20201208141808

FACILITY NAME:	SHALEV SENIOR LIVING 2		FACILITY NUMBER:	197609330
ADMINISTRATOR:	ELEANOR JIMENEZ		FACILITY TYPE:	740
ADDRESS:	5797 HILLVIEW PARK AVE		TELEPHONE:	(818) 988-3372
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	0	CENSUS: 0	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	02:32 PM
MET WITH:	Rudy Rezzadeh		TIME COMPLETED:	02:53 PM

ALLEGATION(S):

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Failure to comply with reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent telephonic complaint visit for the purpose to deliver findings for the above allegation. At 2:32 p.m., LPA Peraldi called Licensee.

During the initial visit, conducted virtually to implement mitigation measures related the Coronavirus Disease 2019 (COVID-19) on 12/17/2020 at 10:30 a.m., LPA Eva Miller interviewed the Administrator, Eleanor Jimenez, conducted a virtual tour of the physical plant and requested pertinent files and documents. On 08/05/2022 and 08/08/2022, LPA Peraldi conducted telephonic interviews with the Administrator and one (1) staff. On 01/20/203, LPA Peraldi conducted a telephonic interview with the Licensee. Additionally, on 01/20/2023 LPA Peraldi conducted a file review.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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 5

Control Number 29-AS-20201208141808

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: SHALEV SENIOR LIVING 2	FACILITY NUMBER: 197609330
	VISIT DATE: 01/20/2023

NARRATIVE

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Regarding the allegation: Failure to comply with reporting requirements. On 12/08/2020, the Department received a complaint in which it was alleged that the facility did not comply with reporting requirements by not submitting a written report to the licensing agency and to the person responsible for the Resident #1 (R1) within seven days R1’s fall. R1 had an unwitnessed fall on 08/12/2020 and the written incident report was sent to the Department on 08/24/2020, twelve (12) days after the R1’s incident. Furthermore on 01/20/2023, LPA Peraldi conducted a file review and confirmed it was sent on 08/24/2020. Based on the information and documentation gathered throughout the investigation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report was issued to the Licensee via mail and email for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
12/08/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20201208141808

FACILITY NAME:	SHALEV SENIOR LIVING 2		FACILITY NUMBER:	197609330
ADMINISTRATOR:	ELEANOR JIMENEZ		FACILITY TYPE:	740
ADDRESS:	5797 HILLVIEW PARK AVE		TELEPHONE:	(818) 988-3372
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	0	CENSUS: 0	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	02:32 PM
MET WITH:	Rudy Rezzadeh		TIME COMPLETED:	02:53 PM

ALLEGATION(S):

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Failure to comply with physician's orders
Failure to provide adequate supervision
Failure to comply with requirements for sale of a licensed facility

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20201208141808

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: SHALEV SENIOR LIVING 2	FACILITY NUMBER: 197609330
	VISIT DATE: 01/20/2023

NARRATIVE

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In reference to the allegation: Failure to comply with physician's orders. On 12/08/2020, the Department received a complaint in which it was alleged that the facility did not comply with Resident #1’s (R1’s) physicians orders by not ensuring that R1 has R1’s neck brace 24/7. Interviews with the Administrator conducted on 12/17/2020 stated that the Administrator did observe R1 wearing the neck brace. The Administrator also stated that R1 would refuse to eat unless the neck brace was removed. The Administrator stated that staff would constantly remind R1 to wear the neck brace but that R1 would get angry and remove it. During the file review conducted by LPA Peraldi on 01/20/2023, it was noted on the R1’s incident report from R1’s unwitnessed fall on 08/12/2020 that R1 refuses to wear the neck brace 24/7 as ordered by physician. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

In reference to the allegation: Failure to provide adequate supervision. It was alleged that staff did not properly supervise R1. Interview conducted with the Administrator on 12/07/2020 revealed that after R1’s fall that occurred on 08/06/2020 that the staff placed a floor alarm by R1’s bed. The Administrator also stated that staff check on R1 every 10-15 minutes. Additionally, LPA Miller requested pertinent documents regarding R1, however the documents were not sent. On 08/05/2022, LPA Peraldi also requested for documents with the Administrator, but the Administrator stated that the current facility no longer has files from Shalev Senior Living 2. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

In reference to the allegation: Failure to comply with requirements for sale of a licensed facility. It was alleged that during the change of ownership of the facility, that the monthly billing to residents already had the new name and owners, Colony Residential Care LLC not the current owners. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted. A copy of the report was issued to the Licensee via mail and email for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201208141808

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: SHALEV SENIOR LIVING 2	FACILITY NUMBER: 197609330
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/20/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...	1 2 3 4 5 6 7	No POC can be provided as this facility closed on 12/02/20.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by:Based on record review, the licensee did not comply with the section cited above, as the facility failed notify Licensing of R1’s incident within the required time frame, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

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