197610154-4-11-2023-31-AS-EMIR-D7JQJK-20240726121249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610154
Report Date: 04/11/2023
Date Signed: 04/11/2023 11:39:47 AM

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
04/06/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230406143049

FACILITY NAME:	A PRECIOUS CARE VILLA		FACILITY NUMBER:	197610154
ADMINISTRATOR:	DOMINGO, OLIVER		FACILITY TYPE:	740
ADDRESS:	8413 RHEA AVE		TELEPHONE:	(818) 626-9343
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 6	DATE:	04/11/2023
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Madonna Olila - Assistant Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff authorized Hospice care for resident without resident's consent.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Mariana Agban and Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with Assistant administrator Madonna Olila and explained the reason for the visit.

LPAs conducted physical plant tour at 9:22 AM, requested copy of facility documents relevant to the investigation at 9:43 AM and conducted interview with resident and staff between 10:00 AM to 11:00 AM. It was alleged that Resident #1 (R1) was asked to sign paperwork for Hospice care and not aware of what R1 was signing, LPAs interview with R1 at 10:00 AM revealed that R1 was aware of what R1 signed and was told of the services the hospice will provide. LPAs interview with the administrator at 10:30 AM revealed that R1 was only admitted at the facility on 04/01/23 at around 6:00 PM and the hospice agency staff arrived at the facility at around 7:00 PM on the same day, further, the administrator has no knowledge of the hospice arrangement or who ordered the hospice services for R1. Based on the information provided the allegation is deemed to be UNSUBSTANTIATED at this time. Exit interview conducted and report been issued.

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: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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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