197609827-9-20-2022-29-AS-KHEN-CJNRBW-20220927125325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609827
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:44:04 AM

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
05/13/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20200513103623

FACILITY NAME:	VIP SENIOR LIVING LLC		FACILITY NUMBER:	197609827
ADMINISTRATOR:	AYLLON, MADELEINE		FACILITY TYPE:	740
ADDRESS:	5457 WOODMAN AVE		TELEPHONE:	(818) 994-4116
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	09/20/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Merlin Mendiola, Caregiver		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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FAILURE TO PROVIDE SUFFICIENT CARE

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver findings for the above allegation. At 10:30 a.m., the LPA was greeted and screened by staff. At 11:15 a.m., the LPA spoke with the Licensee, Jeffrey Alvarez and explained the reason for the visit. The Licensee was not available during the time of the visit, and authorized staff Merlin Mendiola to sign the report.

During the initial visit, conducted virtually to implement mitigation measures related the Coronavirus Disease 2019 (COVID-19) on 05/22/2020 at 9:00 a.m., LPA Eva Miller interviewed the Licensee, and requested pertinent files and documents. On 09/07/2022, LPA Peraldi conducted a record review of the available and submitted documents. On 09/08/2022, LPA Peraldi conducted interviews with Resident #1’s (R1’s) hospice nurse. Additionally, on 09/08/2022, LPA Peraldi attempted to interview R1’s emergency contact/representative.
Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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-20200513103623

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: VIP SENIOR LIVING LLC	FACILITY NUMBER: 197609827
	VISIT DATE: 09/20/2022

NARRATIVE

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Regarding the allegation: Failure to provide sufficient care.
On 05/13/2020, the Department received a complaint in which it was alleged that the facility staff did not provided sufficient care to R1 subsequent to an injury sustained in a fall while in the facility resulting in a decline in medical condition. Interview conducted on 05/22/2020, with the Licensee confirmed that R1 fell and sustained a broken arm on or around the date 04/30/2020. The Licensee explained that R1 was mopping the floor prior to the fall. The Licensee explained that R1 enjoyed cleaning and that staff would advise R1 not to clean. The Licensee stated that they were present during the fall, as well as two (2) other staff. The Licensee explained that after the fall, they made cleaning equipment’s such as mops inaccessible. After R1’s fall and hospitalization, R1 was discharged back to the facility with Home Health Services to treat a pressure injury and to provide physical therapy. On 09/08/2022, LPA Peraldi attempted to call R1’s emergency contact, but the phone number appeared to be disconnected. On 09/08/2022, LPA Peraldi interviewed R1’s Home Health Nurse. R1’s Home Health Nurse stated that R1 was being taken care of well by facility staff and had no concerns regarding the facility or the facility staff. On 09/07/2022, LPA Peraldi reviewed all available documents and interviews obtained during the previous investigations. LPA Peraldi reviewed a note from R1’s Home Health wound care specialist that stated R1’s wounds were improving and that R1 will benefit from staying at the facility. On 09/08/2022, LPA Peraldi called R1’s Home Health Agency to confirm the contexts of the note and to interview the wound care specialist. However, LPA Peraldi was not able to confirm the note or speak to R1’s wound care specialist as it appeared that R1’s wound care specialist was no longer employed at the home health agency. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted. A copy of the report was issued to the Licensee via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC9099 (FAS) - (06/04)

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