197610165-10-9-2024-31-AS-NGID-DAKP6M-20241031110235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610165
Report Date: 10/09/2024
Date Signed: 10/09/2024 02:50:48 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
10/07/2024 and conducted by Evaluator Perchui Khurshudyan

COMPLAINT CONTROL NUMBER: 31-AS-20241007093121

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: 6	DATE:	10/09/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Cherie Wood - Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not keep deceased resident's personal information confidential.

INVESTIGATION FINDINGS:

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On 10/9/2024 at approximately 9:45am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced ten day initial complaint investigation visit. Upon arrival LPA met with the Administrator Cherry Wood and explained the reason for the visit.

At approximately 11:30am, LPA conducted a physical plant inspection with the help of an Administrator to assure the health and safety of the residents in care. During today's visit, LPA obtained copies of pertinent documents, collected staff and residents' rosters, interviewed Administrator from 10:15am to 11:15am to discuss the allegation.
It was reported that facility staff members trashed residents' personal belongings which include clothes and medical reports in front of the facility visible and accessible to people in the neighborhood. During the interview, the administrator stated that they decided to clean and organize the storage where they keep very old records from 2016 and residents’ clothes that were never picked up by the relatives.
Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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-20241007093121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
	VISIT DATE: 10/09/2024

NARRATIVE

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Administrator also stated that she follows the Title 22 regulations and knows that staff is responsible to hold all the records for three (3) years, however, these old boxes of records from 2016 were never shredded. The Administrator also admitted to LPA that they made a mistake and were not supposed to leave confidential records outside visible to others. LPA informed the administrator that per Title 22 regulations he/she is violating the residents’ personal rights by exposing residents' personal and confidential records to the public. Based on the interview and information provided during the course of the investigation, the allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 under CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D), appeal rights discussed.

Exit interview conducted and copy of report issued and delivered to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20241007093121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/11/2024 Section Cited CCR 87468.2(a)(2)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights...(a)In addition to the rights listed in Section 87468.1...(2)To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator and staff will conduct training on Personal Rights of Residents and will provide copy of the training materials to RO/LPA by the POC due date, which is 10/11/24.
	8 9 10 11 12 13 14	Based on the observation and interviews the administrator violated residents personal rights by exposing residents' personal and confidential records to the public which poses immediate Health, Safety or Personal Rights risks to person 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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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