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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603012
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:45:40 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
09/05/2019 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20190905095551
FACILITY NAME:NORTHRIDGE RETIREMENT VILLA, LLCFACILITY NUMBER:
197603012
ADMINISTRATOR:LANI A. MANZANOFACILITY TYPE:
740
ADDRESS:18901 LIGGETT STTELEPHONE:
(818) 203-9411
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lani Manzano/ AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff overcharging resident.

Staff administered medication to resident without permission.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at this facility in response to the above mentioned allegations. LPA was greeted by the facility staff and the administrator arrived a short while later at about 9:30 AM.
Allegation 1. Staff overcharging resident
LPA was able to speak to the facility administrator as well as facility residents in order to come to a finding regarding this allegation. Interviews with the facility administrator conducted on 9/16/19, indicated that the administrator would not seek payment for a resident in question (R1). The administrator stated that the rental agreement states that a refund would only be permitted in the event of a residents death or after a written 30 day notice has been provided to the administrator. The administrator indicated that although she is entitled to payment, they decided to waive this cost. Three out of the five residents currently living at the home, were also interviewed during todays visit and all residents confirmed that they are not being over charged nor have they had any issues with the payment.
Continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20190905095551
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: NORTHRIDGE RETIREMENT VILLA, LLC
FACILITY NUMBER: 197603012
VISIT DATE: 10/26/2021
NARRATIVE
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At 10:30 AM, LPA was able to speak with the complainant of this allegation, who confirmed that this charge was removed and that the R1 did not have to make payment and R1 was not over charged for their stay.
Based on confirmation from the administrator and the complainant, this allegation is deemed UNSUBSTANTIATED at this time.

Allegation 2. Staff administered medication to resident without permission.

At 10 AM, LPA was able to review the medication log for R1. All medications were accounted for and documented. At 10:45 AM, LPA was able to interview the residents living at the facility. Out of the 5 residents at the home, only 3 residents were verbal and were able to answer the LPA's questions. 3 out of the five residents interviewed knew which medications they are to take and confirmed that they receive them as prescribed. All residents interviewed, denied ever receiving medications that are not prescribed.

Based on information received from resident and staff interviews, as well as a review of the medication logs, this allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2