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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:35:51 PM

Document Has Been Signed on 09/20/2024 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLAGE AT SHERMAN OAKS, THEFACILITY NUMBER:
197608694
ADMINISTRATOR/
DIRECTOR:		GRACE HARTNETTFACILITY TYPE:
740
ADDRESS:5450 VESPER AVETELEPHONE:
(818) 994-7900
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY: 179CENSUS: 151DATE:
09/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Grace HartnettTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240319161408). LPA met with Executive Director Grace Hartnett and explained the reason for the visit. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

At approximately 9:45 a.m., the LPA reviewed Resident #1 (R1)'s records and found that R1's physician's report (LIC 602) was dated December 20, 2022. The needs and services plan was last updated on June 12, 2024. According to Executive Director Grace Hartnett, staff have made multiple attempts to obtain the LIC 602 from Kaiser but have been unsuccessful. Staff contacted Kaiser again today, September 20, 2024, to request an updated LIC 602 and will inform the LPA once it is received.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed and copy of reports issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2024 01:35 PM - It Cannot Be Edited


Created By: Brian Balisi On 09/20/2024 at 12:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SHERMAN OAKS, THE
FACILITY NUMBER: 197608694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87705(c)(5)

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Each resident with dementia shall have an annual medical assessment as specified in section 87458, medical assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident' dementia care needs. This requirement is not met as evidenced by:
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Licensee agreed to obtain an updated LIC 602 and send to LPA via email by 10/04/2024 COB.
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Based on record review, the licensee did not comply witht he section cited above as R1 Physician's report (LIC602) is dated 12/20/2022 which poses a potential health and safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
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