197609827-5-16-2023-29-AS-DPEA-CSD3B3-20230531180539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609827
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:17:19 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
05/08/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230508153422

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: 6	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Jeffrey Alvarez, Licensee		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not communicate authorized representative.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced 10-day initial complaint visit to this facility. 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.

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 29-AS-20230508153422

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: 05/16/2023

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

Regarding the allegation: Facility did not communicate authorized representative. On 05/08/2023, the Department received a complaint regarding the Licensee and facility not communicating with Resident #1’s (R1’s) authorized representative. Interview with Staff #1 (S1) at 10:09 a.m., revealed that S1 did have communication with R1’s authorized representative while R1 was at the facility. Interview conducted with the Licensee at 10:34 a.m., explained that the Licensee did have contact with R1’s authorized representative. The Licensee explained that he communicated with R1’s authorized representative through phone calls. The Licensee stated that R1’s authorized representative did not have an email address or other forms of communication. The Licensee explained that when R1 passed away, the Licensee and R1’s hospice agency both notified R1’s authorized representative of R1’s passing via a telephone call. Additionally, the complainant did state that R1’s authorized representative did receive a call from the facility notifying R1’s authorized representative of R1’s death. The Licensee also stated that he has since attempted to contact R1’s authorized representative after R1’s passing but that R1’s authorized representative has not answered the Licensees telephone calls. The LPA reminded the Licensee to constantly report and communicate with residents’ representatives both verbally and in a written report as described in regulation 87211 Reporting Requirements. 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 at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 2