197610006-6-20-2023-31-AS-EMIR-D8KMGT-20240828093628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610006
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:41:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
06/15/2023 and conducted by Evaluator Mariana Agban

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230615142620

FACILITY NAME:	NORTHRIDGE VILLA FOR ELDERLY, INC.		FACILITY NUMBER:	197610006
ADMINISTRATOR:	WIJERATHNA, RONIKA		FACILITY TYPE:	740
ADDRESS:	8419 YOLANDA AVENUE		TELEPHONE:	(818) 812-9599
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 2	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Nita Wilmalaratne- Caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not keep resident(s) free from punishment, humiliation, intimidation, abuse or other acts of a punitive nature.
Staff did not provide necessary care for resident(s) with restricted health condition(s)
Staff did not provide adequate quantity and/or quality of food to resident(s)
Facility is not kept clean, safe and sanitary.
Administrator is not on the premises a sufficient number of hours to adequately manage the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mariana Agban and Licensing Program Manager (LPM) Eva Miller conducted an initial unannounced investigative visit for the purpose of this complaint.

Upon arrival,LPA and LPM spoke with the Administrator on the phone. The Administrator advised she would arrive at the facility in approximately two hours. LPA & LPM met with Staff and explained the reason for the visit. Between 1:30 PM - 2:30 PM LPA and LPM conducted file review and interviewed Staff #1 (S1) and Staff #2 (S2) (2 of 2 Staff). At 2:45 PM LPA and LPM conducted a physical plant tour of the facility to assure the health and safety of the residents. LPA and LPM didn't observe any health and safety concerns. From 3:00- 3:15 LPA and LPM conducted interviews for Resident #2 (R2) and Resident #3 (R3) (2 of 2). At 3:10pm the Administrator called and advised she would not be able to arrive until 5:30pm. The LPA & LPM advised that they would not be able to wait.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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 4

Control Number 31-AS-20230615142620

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTHRIDGE VILLA FOR ELDERLY, INC.	FACILITY NUMBER: 197610006
	VISIT DATE: 06/20/2023

NARRATIVE

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Allegation: Staff did not keep resident(s) free from punishment, humiliation, intimidation, abuse or other acts of a punitive nature.
The complainant advised that Resident #1 (R1) and staff #1 had a verbal argument. S1 made a threatening statement while holding a knife. Information obtained by LPA and LPM from interviews includes the following:
staff 1 denied the allegation. Staff 2 denied the allegation. A witness advised that the conversation between staff1 and resident 1 was in a foreign language and the witness did not understand. The witness didn't observe any obvious hostility and didn't cooperate the allegation of the knife. Interview(s) with other resident(s) did not include any corroborating statement.

Allegation: Staff did not provide necessary care for resident(s) with restricted health condition(s)
The complainant advised that resident 2 has a restricted health condition and that staff do not provide necessary care. Information obtain by LPA and LPM interviews includes the following:
Resident 2 denied the allegation and advised resident 2 is capable of self care.

Allegation: Staff did not provide adequate quantity and/or quality of food to resident(s)
The complainant advised that food served was in inadequate portions was of poor quality and did not meet residents needs. Information obtained by LPA and LPM from interviews includes the following:
Staff 2 showed pictures of meal served that appeared to be of quality and quantity to meet residents needs. Interviews with residents indicated satisfaction with meal served. LPA and LPM observed an adequate supplies of food both perishable and non-perishable of quality and quantity sufficient to meet the residents needs.

Allegation: Facility is not kept clean, safe and sanitary.
The complainant advised that facility's bathroom in unclean and had cockroaches. LPA and LPM did not observed any evidence of cockroaches or unclean bathrooms.

There's insufficient evidence to either confirm or deny the above allegations. The allegation are deemed UNSUBSTANTIATED. Copy of the report provided and exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
06/15/2023 and conducted by Evaluator Mariana Agban

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230615142620

FACILITY NAME:	NORTHRIDGE VILLA FOR ELDERLY, INC.		FACILITY NUMBER:	197610006
ADMINISTRATOR:	WIJERATHNA, RONIKA		FACILITY TYPE:	740
ADDRESS:	8419 YOLANDA AVENUE		TELEPHONE:	(818) 812-9599
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 2	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Nita Wilmalaratne- Caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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9

Administrator is not on the premises a sufficient number of hours to adequately manage the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mariana Agban and Licensing Program Manager (LPM) Eva Miller conducted an initial unannounced investigative visit for the purpose of this complaint.

Allegation: Administrator is not on the premises a sufficient number of hours to adequately manage the facility

The complainant advised that the Administrator has not been in the facility in months. Information obtained during interviews including statements that the adminstator comes to the faclity on weekends " When she can" The adminstator was not able to join today's investigation visit due to distance between her home and the facility. This allegation is SUBSTANTIATED.

Citation issued, appeal rights provided, copy of 9099 provided and exit interview conducted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20230615142620

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTHRIDGE VILLA FOR ELDERLY, INC.	FACILITY NUMBER: 197610006
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/20/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	ADMINISTRATOR QUALIFICATIONS:The administrator shall have sufficient freedom from other responsibilities & shall be on the premises a sufficient number of hours to permit adequate attention to the management &administration of the facility. This reqiurement was not met	1 2 3 4 5 6 7	The Administrator stated that she will close the faciltiy and surrender her license in accordance with CCR Regulations. Eviction notices will be issued. A letter of intent to close will be submitted to CCL. She has already contacted the ALW personnel for the purpose of placement of residents.
	8 9 10 11 12 13 14	Based on observations, & interviews w/staff & Residents the Administrator does not spend a sufficient number of hours at the facility to adequately administer & manage the facility. Resulting in the potential risk to the health and safety of 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4