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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191201867
Report Date: 06/18/2021
Date Signed: 06/21/2021 02:58:14 PM

Unsubstantiated


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
02/19/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20210219150134
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: 110DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kathleen Glass/ AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal items.

Facility did not reimburse former resident's authorized representative.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Patrick Shanahan and Melissa Ruiz arrived at the facility in order to investigate the allegations above. LPA's were greeted by the facility administrator and the and the reason for the visit was explained.
Allegation 1. Staff did not safeguard resident's personal items.
At 9:00 am LPAs requested the resident in questions (R1) facility file and pertinent documentation. R1 was independent and would come and go to the facility. An inventory of personal items was conducted upon admittance in 2014 and some of the items in question were observed to be there. In December of 2020 R1 was admitted to the hospital and R1's family requested specific items from R1's room and another inventory of personal items was requested. Cash, jewelry, and other valuables were noted and given to the family. When R1 passed away in 2021, a final inventory of personal items was conducted and no jewelry or other specified items were noted or observed by staff.

Cont. on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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