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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191201867
Report Date: 04/09/2021
Date Signed: 04/09/2021 10:35:24 AM

Unfounded


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
04/02/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20210402100850
FACILITY NAME:EISENBERG VLG OF THE LA JEWISH HOME FOR THE AGINGFACILITY NUMBER:
191201867
ADMINISTRATOR:GLASS, KATHLEEN K.FACILITY TYPE:
740
ADDRESS:18855 VICTORY BOULEVARDTELEPHONE:
(818) 774-3000
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:271CENSUS: 118DATE:
04/09/2021
UNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Kathleen GlassTIME COMPLETED:
10:42 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit a resident with an object while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patrick Shanahan conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with administrator, Kathleen Glass, at 9:00 am and explained the purpose of the visit.
LPA conducted a physical plant tour at about 9:15 am. LPA was also able to obtain and review facility records and pertinent documents relevant to the investigation. While reviewing the staff schedule and the facility census, LPA observed that both the resident in question and the staff in question were not on the lists provided. The facility administrator confirmed that neither one of the individuals in question worked or lived at this facility and that this incident occurred next door at a skilled nursing facility. Based on the information gathered during this visit. The allegation is deemed unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.
Exit interview conducted and report issued.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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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