197609928-10-7-2022-31-AS-RRAZ-CKJN3R-20221025100646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609928
Report Date: 10/07/2022
Date Signed: 10/07/2022 11:26:25 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2021 and conducted by Evaluator Patrick Shanahan

COMPLAINT CONTROL NUMBER: 31-AS-20210210133149

FACILITY NAME:	COVELLO TOP NOTCH CARE LLC		FACILITY NUMBER:	197609928
ADMINISTRATOR:	LOPEZ, DAVID		FACILITY TYPE:	740
ADDRESS:	18807 COVELLO STREET		TELEPHONE:	(818) 855-9615
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	10/07/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	David Lopez		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff falsify documentation

Staff failed to meet the resident's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home in order to conduct the investigation for the above mentioned allegations. The LPA was greeted by the facility staff and explained the reason for the visit.
Allegation 1. Staff falsify documents
The LPA was able to interview staff, the resident's (R1) responsible party and the home health nurse regarding this allegation. LPA was also able to review R1's medical documentation. Interviews with the home health nurse revealed, that there was a misunderstanding regarding treatment that the facility is able to provide and what must be administered by a medical professional. The home health nurse was also unaware of the most recent appraisal of R1. A review of medical documents such as the physician's report, R1's needs and services plan and resident appraisal were in tact and there were no indications that staff had falsified documentation. Based on interviews conducted and a review of R1's medical documentation, this allegation is deemed UNSUBSTANTIATED.
Continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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 31-AS-20210210133149

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COVELLO TOP NOTCH CARE LLC	FACILITY NUMBER: 197609928
	VISIT DATE: 10/07/2022

NARRATIVE

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Allegation 2. Staff failed to meet the resident's needs
The LPA was able to interview staff, residents, home health nurse and R1's power of attorney (POA). Facility staff interviewed confirmed that staffing is never an issue and that they can meet the needs of the residents. R1's POA, also confirmed that facility staff is able to meet the needs of the residents. The home health nurse was interviewed and once informed of the facility limitations also confirmed that the facility is able to meet the needs of the residents in care. The LPA was also able to review the staffing schedule for the facility and it indicated that staffing is sufficient to meet the needs of the residents at the home. Based on interviews and a review of the facility staffing schedule, this allegation is deemed to be UNSUBSTANTIATED.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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