197609786-8-12-2022-29-AS-KHEN-CHRVPS-20220829163714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609786
Report Date: 08/12/2022
Date Signed: 08/12/2022 12:33:30 PM

Unsubstantiated

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
01/22/2021 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20210122100837

FACILITY NAME:	WOODLAND HILLS RETIREMENT HOME		FACILITY NUMBER:	197609786
ADMINISTRATOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	24301 OXNARD ST		TELEPHONE:	(818) 564-4381
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 4	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Serguei Kalistratov		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Facility is not meeting resident's need to have transportation arranged.
Facility is not serving food of the quality or quantity to meet resident's needs.
Facility is not meeting the requirements pertaining to fee increase for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted virtually on 2/01/2021 by LPA A. Richardson and a subsequent visit was conducted on 7/08/2022 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Administrator, Serguei Kalistrov. Entrance interview conducted.

During the initial visit on 2/01/2021, LPA A. Richardson conducted a telephonic interview the Administrator at 3:00 p.m. and requested copies of resident records. During the subsequent visit on 7/08/2022, LPA M. Arroyo conducted a tour of the facility at 1:00 p.m. and conducted interviews with two staff and three residents. At 1:08 p.m., the LPA began record review of resident files and obtained copies of resident records and other pertinent documents relevant to the investigation. The LPA also interviewed family members on 7/13/2022 at 3:01 p.m., and on 7/22/2022 at 4:20 p.m.
…Report Continued on LIC 9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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 29-AS-20210122100837

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 08/12/2022

NARRATIVE

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…Report Continued from LIC 9099…

It was alleged that facility is not meeting resident’s need to have transportation arranged. It was reported that R1 needed assistance from another person to accompany them to their doctor’s appointments. Record review of documents revealed that the facility had agreed to provide transportation to R1 to and from medical appointments. Per R1’s Admissions Agreement dated 07/01/2020, it states on page 4, “basic transportation to and from medical appointments is included within a radius of ten (10) miles on designated days…”. Additionally, R1 was being transported to their medical appointments being scheduled, but still required assistance beyond the transportation. Personal assistance to medical appointments was offered to R1’s responsible person under “Optional Service” for an additional monthly fee on page 3 of the Admissions Agreement which states, “personal escort to appointments”. However, this additional service was declined by R1’s responsible person upon admission to the facility on 07/01/2020. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “facility is not meeting resident’s need to have transportation arranged”. Therefore, the allegation is deemed Unsubstantiated at this time.

It was also alleged that facility is not serving food of the quality or quantity to meet resident’s needs. It was reported that facility was only serving spaghetti and residents were not eating enough. During the visit on 07/08/2022, the LPA observed the kitchen and food supply. The facility had a variety of food including fruits, vegetables, milk, meats, eggs, and bread. Interviews with staff revealed that meals are cooked for the residents every day, and although the facility does not have menus, the residents have expressed no concern with the food served. Additionally, some residents have a favorite food that they prefer, which the staff will make for them more frequently. Family members stated no concerns with the quality of food and added that the staff has even tried many different ways to accommodate the residents to make sure they eat what they enjoy. Based on interviews and LPA observation, the Department does not have sufficient evidence to support the allegation of “facility is not serving food of the quality or quantity to meet resident's needs”. Therefore, the allegation is deemed Unsubstantiated at this time.

It was further alleged that facility is not meeting the requirements pertaining to fee increase for resident. It was reported that R1 had only been at the facility for one month before receiving a notice that the rate fee would be increasing. Information obtained revealed that the Administrator of the facility had mailed out a letter indicating the facility’s monthly fee increase of $1,000.

...Report Continued on LIC 9099C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210122100837

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 08/12/2022

NARRATIVE

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…Report Continued from LIC 9099…

The letter mailed out to R1’s responsible person was dated 12/01/2020 and indicated the fee increase would be effective 02/01/2021. Additionally, the fee increase letter given to residents outlined specific reasons as to why the fee increase was primarily due. Furthermore, per R1’s Admissions Agreement, it was revealed that R1 was admitted to the facility on 07/01/2020, which was seven months before the expected fee increase was to take in effect. Interviews conducted revealed that the Administrator had given a two month notice to residents residing at the facility before 12/01/2020 regarding the $1,000 fee increase. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility is not meeting the requirements pertaining to fee increase for resident”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

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