197610165-11-10-2022-31-AS-EMIR-CLVNY8-20221207095215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610165
Report Date: 11/10/2022
Date Signed: 11/10/2022 01:46:04 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
11/08/2022 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20221108124245

FACILITY NAME:	MCNULTY VILLA		FACILITY NUMBER:	197610165
ADMINISTRATOR:	WOOD, CHERIE		FACILITY TYPE:	740
ADDRESS:	20724 MCNULTY PL.		TELEPHONE:	(818) 395-6037
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 5	DATE:	11/10/2022
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Cherie Wood, Jing Struve		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff relocated resident to another facility without proper notice to resident's responsible party.
Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Cherie Wood, and advised her of the allegations. LPA then spoke with the licensee designee Jing Struve over the telephone and also advised her of the allegation. From approximately 9:15am to 11:00am, interviews were made to discuss the allegation. From 11:00am to 12:00pm, LPA reviewed Resident 1's (R1) records. From 12:00pm to 12:30pm, LPA took a tour of the physical plant to insure that the facility continues to remain compliant.

Facility staff relocated resident to another facility without proper notice to resident's responsible party:
In regards to the allegation, it was reported that R1's responsible person or contact person was not given proper notice that licensee was going to move R1 to another facility. Interviews with both the administrator and the licensee representative confirmed that no written notice was given to either R1 or their responsible/contact person. Prior to the investigation, LPA did make contact with R1's contact person, who also

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

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-20221108124245

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: MCNULTY VILLA	FACILITY NUMBER: 197610165
	VISIT DATE: 11/10/2022

NARRATIVE

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confirms that they were given short notice that R1 was being transferred to another facility, and that nothing in writing was provided to neither the contact person or R1. Based on the information obtained, the allegation of resident being relocated to another facility without proper notice is Substantiated. Citation issued on the 9099D. Appeal rights given.

Unlawful Eviction:
In regards to the allegation, it was reported that R1 was transferred to another facility without the proper written notification. Interviews with both the administrator and the licensee designee confirms that a written notice wasn't provided to R1 or their responsible/contact person. Interview with the responsible/contact person to R1 also confirms that written notice was provided. Furthermore, interviews and record review does not indicate R1 experienced a change in condition since R1's admission into facility in February 2022. There was no documentation on file indicating that the facility could no longer meet R1's needs. Based on the information obtained, the allegation of Unlawful Eviction is Substantiated. Citations issued on the 9099D. Appeal rights given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20221108124245

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: MCNULTY VILLA	FACILITY NUMBER: 197610165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/10/2022 Section Cited CCR 87468.2(a)(20)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: Residents in privately operated residential care facilities for the elderly shall have the following personal rights: To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily	1 2 3 4 5 6 7	As POC, both the licensee designee and administrator will review this section of the regulation and self certify that they have read and understood this section. As proof POC is made, a written self-certification is due to the licensing agency by 11/17/22
	8 9 10 11 12 13 14	transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents. This requirement was not met as evidenced by the admission of the licensee that R1 was relocated without proper notice.	8 9 10 11 12 13 14
Type B 11/10/2022 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously	1 2 3 4 5 6 7	Contintued: R1 also did not develop a change in condition in which the facility could no longer meet their needs since being admitted in February 2022. There was no documentation on file.
	8 9 10 11 12 13 14	identified, and/or a change of use of the facility. This requirement was not met as evidenced by the admission from the licensee that R1 was not given proper 30 day notice. Furthermore, it was revealed that R1 was compliant with pay, state & local law and general policies of the facility.	8 9 10 11 12 13 14	As POC, both the licensee designee and administrator will review this section of the regulation and self certify that they have read and understood this section. As proof POC is made, a written self-certification is due to the licensing agency by 11/17/22

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: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC9099 (FAS) - (06/04)

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