197609827-9-20-2022-29-AS-DPEA-CM6TLB-20221216134916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609827
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:43:00 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
04/28/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220428162957

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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Residents not accorded dignity in their personal relationships with staff

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 on 05/04/2022 at 11:20 a.m., LPA Peraldi conducted a physical plant tour and requested pertinent documents. On 05/04/2022 between 11:30 a.m. and 2:40 p.m., LPA Peraldi interviewed the Licensee, one (1) staff and one (1) resident. Additionally, on 09/15/2022, LPA Peraldi interviewed four (4) resident representatives.

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-20220428162957

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: Residents not accorded dignity in their personal relationships with staff.
On 04/28/2022, the Department received a complaint in which it was alleged that the facility staff do not treat the residents well. Interview conducted on 05/04/2022, with the Licensee noted that the Licensee had not seen or heard the facility staff be rude to residents. On 05/04/2022, LPA Peraldi attempted to interview two (2) residents. On 05/04/2022, LPA Peraldi conducted an interview with Resident #1 (R1). R1 stated that the facility staff are nice. On 09/15/2022, between 10:49 a.m. and 1:48 p.m., LPA Peraldi conducted interviews with all four (4) out of four (4) residents’ representatives. During the interviews, no complaints or concerns were brought up. The interviews conducted with residents’ representatives noted that the facility staff treat the residents well. Three (3) out of four (4) resident representatives visit the facility more than once a week. R1’s representative visit R1 daily and have not observed neglect or abuse. Additionally, Resident #2’s (R2’s) representative visit R2 once a week and stated that the facility staff treat R2 well. 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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