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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610151
Report Date: 06/14/2022
Date Signed: 06/14/2022 02:36:25 PM

Substantiated


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
10/04/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20211004100524
FACILITY NAME:AEGIS LIVING GRANADA HILLSFACILITY NUMBER:
197610151
ADMINISTRATOR:SHENK, LANCEFACILITY TYPE:
740
ADDRESS:10801 LINDLEY AVETELEPHONE:
(818) 363-3373
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:100CENSUS: 79DATE:
06/14/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Matthew Le Vine/ AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility accepted resident with prohibited condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to this complaint. Facility staff informed the administrator the reason for the visit.

Allegation 1. Facility accepted resident with prohibited condition.
At 11:30 AM, LPA received copies of the resident in question's (R1) Physician Report, and 3 copies of R1's Individualized Service Assessment/Functional Capabilities, Resident Appraisal. The Physicians Report, dated 9/13/21 (conducted prior to R1's admission date), indicates that R1 had a primary diagnosis of dementia and a secondary diagnosis of quadriplegia. The physicians report also indicated that R1 had no capisity for self care, nor was R1 alble to communicate. Staff interviewed stated that R1, could communicate using simple words but was unable to verbalize needs. All Individualized Service Assessment/Functional Capabilities documents reviewed also indicated that R1 required assistance with all aspects of daily living.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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 3
Control Number 31-AS-20211004100524
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: AEGIS LIVING GRANADA HILLS
FACILITY NUMBER: 197610151
VISIT DATE: 06/14/2022
NARRATIVE
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Based on a review of facility documents, which indicated that R1 was admitted to the facility requiring assistance with all aspects of daily living and staff interviews, this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, appeal rights discussed and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211004100524
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: AEGIS LIVING GRANADA HILLS
FACILITY NUMBER: 197610151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/15/2022
Section Cited
HSC
87615(a)(5)
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87615(a)(5) Prohibited Health Conditions. (a) Persons who require health services ...shall not be admitted or retained in a RCFE: (5) Residents who depend on others to perform all activities of daily living for them as...Section 87459, Functional Capabilities. This requirement is not met as evidenced by:
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The administrator agrees to put in writing his understanding of this regulation and how he and his staff can prevent this from occuring in the future.
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Based on record review and interviews, the licensee retained accepted a resident (R1) who has a prohibited health condition of depending on others to perform all activities of daily living which poses an immediate health and safety risk to the resident 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3