197609767-6-13-2023-31-AS-RORN-D5AKZ3-20240515082003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609767
Report Date: 06/13/2023
Date Signed: 06/13/2023 01:01:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
06/05/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230605091652

FACILITY NAME:	ASSURE CARE VILLA		FACILITY NUMBER:	197609767
ADMINISTRATOR:	PEREGRINO, FLORENCE		FACILITY TYPE:	740
ADDRESS:	8854 OAKDALE AVE		TELEPHONE:	(747) 237-2345
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 6	DATE:	06/13/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Dennis Bonifacio- House Manger		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff do not provide proper food service to resident in care
Staff confiscated resident's personal cell phone

INVESTIGATION FINDINGS:

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On 6/13/2023 at 10:00am Licesing Program Analysts (LPAs) Mariana Agban and Angela Panushkina arrived at the above facility to conduct intitial complaint visit. Upon entrace LPAs were greeted by Staff #1 (S1). Adminstator was contacted and the reason for the visit was explained. LPAs were informed that the Administor wasn't able to come to the facility and designated (S2) to sign for the report.

During course of the investigation, interviews and record review were made. At 10:10am, LPAs met with Staff #2( S2) and requested resident and staff roster. At approximately 10:15am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Physician’s report, Appraisal Needs and Services Plan, Resident Valuable, etc., relevant to the investigation. Between 10:10am -11:45am, LPAs interviewed the Administrator, two (2) staff members and five (5) out of six (6) residents.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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-20230605091652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSURE CARE VILLA	FACILITY NUMBER: 197609767
	VISIT DATE: 06/13/2023

NARRATIVE

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Allegation: Staff do not provide proper food service to resident in care

Regarding the allegation that staff do not provide proper food service to resident care, LPA's interview with five (5) out of six (6) residents revealed that the facility provides three (3) meals and snacks in between every day and that they all have an access to the kitchen at any time. Five (5) out of six (6) residents also informed LPAs that the staff will provide an extra meal upon request. In addition, interview with the Administrator and two (2) staff members revealed that the facility always provides three balanced meals and snacks in between and extra portions are available upon request. Lastly, S2 informed LPAs that the facility will also customize food being served upon resident's request. Based on the information gathered during this visit, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff confiscated resident's personal cell phone

Regarding the allegation that staff confiscated resident's personal cell phone, LPAs conducted an interview with the Administrator and two (2) staff members and were informed that two (2) out of six (6) residents have a cell phone and one (1) out of six (6) residents have a private land line. All staff denied ever restricting residents from using a phone or confiscating a cell phone from the resident. Interviews with five (5) residents revealed that they have a free and full access to the phone at any time. In addition, two (2) out of (6) residents, who's in a possession of a cell phone, informed LPAs that the facility staff has never confiscated their cell phones.Based on interviews during the course of the investigation this allegation is deemed Unsubstantiated at this time.

No deficiency issued.
Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC9099 (FAS) - (06/04)

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