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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609767
Report Date: 10/14/2024
Date Signed: 10/15/2024 09:26:40 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
12/06/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20231206155759
FACILITY NAME:ASSURE CARE VILLAFACILITY NUMBER:
197609767
ADMINISTRATOR:PEREGRINO, FLORENCEFACILITY TYPE:
740
ADDRESS:8854 OAKDALE AVETELEPHONE:
(747) 237-2345
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
10/14/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Florence PeregrinoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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The facility retained a resident with a prohibited health condition.
Staff did not seek timely medical care for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban met with the Administrator, Florence Peregrino, to conduct an unannounced subsequent complaint visit to deliver the findings regarding the allegations, listed above. An entrance interview was conducted.

On 12/06/23, Complaint 31-AS-20231206155759 was received by the Woodland Hills Adult & Senior Care Regional Office. Complaint 31-AS-20231206155759 was referred to the Community Care Licensing Division’s Investigation Branch (IB) on 12/07/23 as an assignment to investigate the complaint. A complete investigation was conducted by IB Investigator, Heidy Bendana, for Case #LD3123-12524. An initial visit was made by Licensing Program Analyst (LPA) Mariana Agban on 12/08/23. LPA conducted a walk through the facility to ensure the health and safety of the resident in care, on this day, no issues were observed. LPA conducted a records review and obtained copies of the Residents' roster, Staff roster, R1’s Admission Agreement, Physician’s Report, and Special Incident Report (SIR) reporting that R1's health condition was declining.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
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-20231206155759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASSURE CARE VILLA
FACILITY NUMBER: 197609767
VISIT DATE: 10/14/2024
NARRATIVE
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R1 was receiving wound care under hospice care once a week and a home health nurse twice a week. Staff were repositioned R1 every two hours as instructed by hospice and changed dressing if wet as instructed. Per medical records, R1’s wounds were treated and were not neglected or infected. The progression of R1’s wounds did not indicate neglect or failure to seek medical care. R1 received medical care; therefore, the allegation is deemed Unsubstantiated.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2