197609342-5-23-2024-31-AS-NMAN-D6DLPM-20240619085611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609342
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:21:57 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240521173105

FACILITY NAME:	LOS FELIZ GARDENS		FACILITY NUMBER:	197609342
ADMINISTRATOR:	SHAPIRO, NONNA		FACILITY TYPE:	740
ADDRESS:	205 E LOS FELIZ ROAD		TELEPHONE:	(818) 241-2273
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 114	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nona Shapiro		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not give resident's records to resident's responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the Executive Director (ED), Nona Shapiro, and explained the reason for the visit.

--- Staff did not give resident's records to resident's responsible party.

It was alleged that facility did not provide a complete copy of Resident #1’s (R1) records. To investigate this allegation, on 05/23/2024, LPA interviewed the ED from around 1:30 PM – 2:00 PM, and requested all documents that were sent to the responsible party (RP) at around 2:00 PM. During the interview with the ED, they stated documents were requested by R1’s RP on 04/19/2024. After receiving the request from the RP, ED stated they sent partial documents, contacted the RP explaining that remaining documents will take additional time and RP allegedly replied, “take your time”.
(CONT. on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240521173105

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: LOS FELIZ GARDENS	FACILITY NUMBER: 197609342
	VISIT DATE: 05/23/2024

NARRATIVE

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ED stated the additional documents were mailed to the RP on 05/16/2024. A review of the records that facility provided to the RP revealed that Home Health records, hospital discharge documents, medication records, needs and service plans and physician’s reports were partially or entirely missing from the set of documents.

Based on interviews and record review, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240521173105

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: LOS FELIZ GARDENS	FACILITY NUMBER: 197609342
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/30/2024 Section Cited CCR 87468.2(19)	1 2 3 4 5 6 7	87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities-To have prompt access to review all of their records and....shall be provided within two (2) business days…This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator will review regulation 87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities and submit a written statement ensuring that they will adhere them and submit all missing documents to the responsible party by the POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure all records were provided to the responsible party which poses a potential personal right violation 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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