197609496-1-17-2025-31-AS-NMAN-DKVW47-20250825165704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609496
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:55:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/16/2025 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250116144714

FACILITY NAME:	ENCINO TERRACE SENIOR LIVING		FACILITY NUMBER:	197609496
ADMINISTRATOR:	JANNAT, SHAHRZAD		FACILITY TYPE:	740
ADDRESS:	16025 VENTURA BLVD		TELEPHONE:	(818) 986-8466
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	85	CENSUS: 59	DATE:	01/17/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Vice President of Operations (VPO), Joel Schochet		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Due to lack of supervision, resident was restrained by another resident causing injuries

INVESTIGATION FINDINGS:

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At 10:15a.m. Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced initial visit to investigate the above stated allegation. LPA met with the VPO and explained the reason for the visit.

At 10:30a.m. LPA Alvizar-Ettima requested the staff, and facility residents’ roster, as well as the rosters for residents that temporarily were relocated in this facility due to Eaton Fire. At 10:45a.m. LPA Alvizar-Ettima and VPO conducted physical plant tour. Between 10:50a.m. – 11:20a.m. LPA conducted interviews with VPO and staff. LPA Alvizar- Ettima asked questions relevant to the nature of the complaint. In addition, at 11:53a.m. LPA reviewed available rosters for facility residents and temporality relocated residents.

Due to lack of supervision, resident was restrained by another resident causing injuries.

Cont. LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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-20250116144714

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENCINO TERRACE SENIOR LIVING	FACILITY NUMBER: 197609496
	VISIT DATE: 01/17/2025

NARRATIVE

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It was alleged that resident #1 (R1) allegedly was seen tied up to a chair with a blanket by resident #2 (R2). Interviews with Administrative personnel, caregiver and Med-Tech. revealed that they have not witnessed R1, or any other resident restrained/tied to a chair. Staff indicated that R1 and R2 are not resident of the facility and may have been residents temporarily living at the facility due to Eaton Fire. At the time of this visit, LPA attempt to interview temporarily relocated residents. However, residents were no longer at the facility. During investigation, LPA did not observe residents restrained/tied to a chair in the facility. LPA Alvizar - Ettima reviewed facility and Eaton residents rosters and noted that R1 was a temporarily relocated resident. R2’s name was not on the list.

Based on observation, interviews, and record review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit Interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC9099 (FAS) - (06/04)

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