197609827-8-30-2022-29-AS-DPEA-CM6VRM-20221216154010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609827
Report Date: 08/30/2022
Date Signed: 08/30/2022 04:03:57 PM

Substantiated

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
08/23/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220823141610

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: 4	DATE:	08/30/2022
		UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:	Merlin Mendiola, Caregiver		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not follow COVID-19 health and safety protocol

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Emily Peraldi arrived unannounced to conduct an initial 10-day visit. At 12:33 p.m., the LPA met with staff and explained the reason for the visit. At 12:45 p.m., the LPA spoke with the Licensee over the phone. The Licensee was not available during the time of the visit, and authorized staff Merlin Mendiola to sign the report.

At 1:02 p.m., the LPA along with staff conducted a brief physical plant tour. Between 1:04 p.m. and 3:41 p.m., the LPA conducted interviews with three (3) staff and the Licensee.

Continued on LIC 9099-C.

Substantiated

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: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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 3

Control Number 29-AS-20220823141610

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: 08/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was alleged that staff in the facility were not following COVID-19 health and safety protocols, including not wearing a mask or not properly wearing a mask while in close contact with the residents. Upon arrival to the facility, Staff #1 (S1) was not wearing the mask properly, by having the mask under the chin. At 12:34 p.m., S1 checked the temperature of the LPA, however S1 did not screen for COVID 19 symptoms. At 12:35 p.m., the LPA observed Staff #2 (S2) properly wearing a mask. At 12:47 p.m., Staff #3 (S3) approached the LPA initially without a mask, but later returned with a mask on. Throughout the visit, the LPA observed S1 and S2 placing the mask under the chin, but once observed by the LPA, S1 and S2 would wear the mask properly.
Furthermore, information obtained from a credible witness confirmed on 08/16/2022, that a credible witness was not screened by facility staff and noted that Staff #4 (S4) and other staff were not wearing masks while in close proximity of residents. At 3:41 p.m., the Licensee explained that the facility will be conducting an in-service training for all the facility staff regarding the most up to date COVID-19 health and safety protocols.

Based on the observation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20220823141610

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/31/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	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 accommodations... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agreed to do the following: Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol and provide training records to CCL by 08/31/2022.
	8 9 10 11 12 13 14	Based on observations from LPA and a credible witness, the licensee did not comply with the section cited above, as staff were not were not following COVID-19 health and safety protocols, including not wearing a mask, which poses an immediate personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3