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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609827
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:19:22 PM


Document Has Been Signed on 05/16/2023 02:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LLCFACILITY NUMBER:
197609827
ADMINISTRATOR:AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:5457 WOODMAN AVETELEPHONE:
(818) 994-4116
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
05/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Jeffrey Alvarez, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi initiated a Case Management – Deficiencies visit to address deficiencies observed during a complaint investigation conducted on 05/16/2023 at the above location. At 9:28 a.m., the LPA met with staff and explained the reason for the visit. At 10:33 a.m., the Licensee arrived at the facility. Between 10:00 a.m. and 10:08 a.m., the LPA along with staff conducted a brief physical plant tour. Between 10:01 a.m. and 10:06 a.m., the LPA also interviewed four (4) out of six (6) residents. Between 10:09 a.m. and 10:30 a.m., the LPA conducted an interview with two (2) staff. At 10:34 a.m., the LPA conducted an interview with the Licensee. At 10:45 a.m., the LPA reviewed records and obtained copies of pertinent documents.

Prior to visit, the LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed Staff #1 (S1) was recently hired. Per record review, conducted by the LPA on the Guardian website, S1 does have fingerprint clearance but is not associated to this facility. Interviews with the Licensee and staff revealed that S1 started working at this facility on 05/15/2023. The Licensee stated that he will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility. At 10:45 a.m., the LPA reviewed Resident #1’s (R1’s) records. R1’s death report was not completed or sent to Community Care Licensing Division (CCLD) within the required time frame. The Licensee explained that the facility was waiting for R1’s death certificate to send the death certificate along with the death report to CCLD. R1 passed away in January 2023 and the Licensee explained that him and his staff were very busy at the time. The Licensee agreed to complete and send a death report to CCLD for R1.
Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $200. Failure to correct the deficiencies may result in additional civil penalties.
Exit interview conducted, A copy of today's reports and appeal rights were provided. Civil penalties issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2023 02:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance
All individuals subject to a criminal record review pursuant to ...shall prior to working... (2) Request a transfer of a criminal record clearance...This requirement is not met as evidenced by:
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Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 05/17/2023.

Civil Penalties assessed in the amount of $200.
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Based on record review and interview the licensee did not comply with the section cited by not transferring the criminal record clearance for S1 to this facility prior to employment which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
05/19/2023
Section Cited
CCR87211(a)(1)(A)

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87211 (a)(1)(A) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports...1)A written report shall be submitted to the licensing agency...(A)Death of any resident… This requirement is not met as evidenced by:
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The Licensee agreed to submit a statement of understanding for the above regulation to CCLD.
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Based on record review and interview, the licensee did not comply with the section cited above as the facility is not following reporting requirements by not reporting R1’s death to CCLD which poses a potential health, safety and personal rights risk to persons in care.
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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 HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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