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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609496
Report Date: 04/07/2025
Date Signed: 04/07/2025 01:33:04 PM

Substantiated


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
04/01/2025 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250401113558
FACILITY NAME:ENCINO TERRACE SENIOR LIVINGFACILITY NUMBER:
197609496
ADMINISTRATOR:JANNAT, SHAHRZADFACILITY TYPE:
740
ADDRESS:16025 VENTURA BLVDTELEPHONE:
(818) 986-8466
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:85CENSUS: 35DATE:
04/07/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Katia Arriaga, Business ManagerTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Licensee did not ensure passageways were maintained free of hazards
Licensee did not ensure elevators were maintained in working condition
Facility does not have Evacuation Plan
INVESTIGATION FINDINGS:
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On 04/07/25, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Business Manager, Katia Arriaga. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint.

On 04/07/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/07/25, LPA Saucedo conducted a physical tour and interviewed staff and residents.

LIC 9099C-continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
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 4
Control Number 31-AS-20250401113558
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: 04/07/2025
NARRATIVE
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Regarding the allegation: Licensee did not ensure passageways were maintained free of hazards. It is being alleged that because there is construction being conducted there is debris such as piles of carpet, lumber, tiles and shards of glass leaning against the wall creating a hazardous passageway. During LPA’s physical tour, LPA observed construction being conducted on the first and second floor. There was debris such as paint buckets, piles of lumber and fiber glass, ladders, exposed electrical wires and electrical outlets in the passageways, dining hall area and patio area creating a hazardous environment to both residents and staff. LPA interviewed four (4) residents and four (4) staff that confirmed there has been construction being conducted for several weeks now. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time.

Regarding the allegation: Licensee did not ensure elevators were maintained in working condition. It is being alleged that the elevator was not working for two (2) days. Although, the elevator is properly working now, it was confirmed by four (4) residents and four (4) staff that the elevator was not previously working. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time.

Regarding the allegation: Facility does not have Evacuation Plan. It is being alleged that there is no emergency exiting plans posted and there is no emergency evacuation plan. During LPA's physical tour, LPA did not observe any emergency exiting plans or/and sketches of the facility on the first or second floor during construction. There is an emergency evacuation plan that is available upon request of the resident and/or resident's family member but the emergency evacuation plan was not provided to the resident and/or resident's family when it was asked to be seen. Resident #1 (R1) and their family member confirmed they have not seen the emergency evacuation plan that they requested. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time.

An exit interview was conducted, citation(s) were issued and the appeal rights were given and a copy of this report was given to the Business Manager.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20250401113558
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by:
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The Administration/Licensee will need to keep the elevator in good repair at all times.

POC Cleared at time of visit: 04/07/25
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Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of the elevator not working which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
04/21/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable acc...This requirement is not met by:
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The Administration/Licensee will need to keep the passageways, electrical outlets covered, electrical wires not being exposed and send a picture to the LPA when the project/construction is completed.

POC Due Date:04/21/25
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Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of construction/ passageways were not free of hazards, exposing of electrical wires/outlets which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20250401113558
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2025
Section Cited
HSC
1569.695(g)
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HSC1569.695- Emergency Plans(g) A facility shall make the plan available upon request to residents onsite, any responsible party for a resident, the local long-term care ombudsman, and local emergency responders...This requirement is not met by:
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The Administration/Licensee will need to have the Emergency Plan available upon request:

POC Due Date: 04/28/25
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Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of the Emergency Plan not being available upon request which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4