197610211-8-8-2023-31-AS-TAGD-CVMN6P-20230913101127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610211
Report Date: 08/08/2023
Date Signed: 08/08/2023 03:55:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
07/21/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20230721160834

FACILITY NAME:	KITTRIDGE RCFE		FACILITY NUMBER:	197610211
ADMINISTRATOR:	MARTIR, FRANCIS		FACILITY TYPE:	740
ADDRESS:	20702 KITTRIDGE ST		TELEPHONE:	(818) 854-6745
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 6	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	James Olalia		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident hit another resident in care.

INVESTIGATION FINDINGS:

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On 08/08/2023 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the above allegation. LPA Spaeth was met by Facility Manager and spoke to the Administrator via phone call at 11:15 am. LPA explained the purpose of this visit was to interview residents and deliver findings for this complaint.

The investigation consisted of the following: On 7/26/2023, LPA Spaeth conducted a 10-day visit, toured the physical plant, interviewed three staff members, interviewed resident (R1), and requested documents. LPA Spaeth requested the following documents: 1) staff roster, and 2) R1 and R2 documentation. All documents were received at the time of visit.

As of today, 8/08/2023, LPA interviewed four residents at 11:15 until 12:20 pm.

Cont on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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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Control Number 31-AS-20230721160834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: KITTRIDGE RCFE	FACILITY NUMBER: 197610211
	VISIT DATE: 08/08/2023

NARRATIVE

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The investigation revealed the following: Regarding the allegation… Resident hit another resident. It’s being alleged a resident in care was hit by another resident during the night of 7/18/2023. LPA interviewed Resident Two (R2) today at 11:15 am who stated was hit by Resident One (R1) during the night. R1 was interviewed on 7/26/2023 at 11:00 am. R1 stated the incident did not happen and stated needs assistance to get in and out of bed to a wheelchair. LPA interviewed Residents Three, Four and Five (R3, R4, and R5) today, 7/08/2023 at 11:45 am until 12:20 pm. R3, R4, and R5 stated did not witness the incident.

LPA interviewed two of the five staff members. Staff Two (S2) was working the night shift on 7/18/2023 at 12:00 am until 6:00 am. S2 stated did not hear any incident occur during the night. S2 stated R2 did not alert S2 that the incident occurred. Staff One (S1) was working the morning of 7/19/2023 at 6:00 am until 6:00 pm. On 7/19/2023 at 11:00 am, R2 stated to S1 that R1 had hit R2 during the night. S1 spoke to R1 on 7/19/2023 at 11:30 am. R1 denied the allegation and stated needs assistance to get out of bed.

Based on LPA’s interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

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