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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609827
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:34:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230711101116
FACILITY NAME:VIP SENIOR LIVING LLCFACILITY NUMBER:
197609827
ADMINISTRATOR:AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:5457 WOODMAN AVETELEPHONE:
(818) 994-4116
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 5DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jeffrey Alvarez, LicenseeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not provide responsible party with a copy of resident's admissions agreement
Staff did not provide responsible party with a copy of resident's facility file
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 1:40 p.m., the LPA met with the Licensee and explained the reason for the visit.

During the initial visit conducted on 07/20/2023 between 10:15 a.m. and 12:30 p.m., LPA Peraldi conducted an interview with the Licensee, conducted a physical plant tour and requested copies of pertinent documents during the time of the visit.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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 5
Control Number 29-AS-20230711101116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
VISIT DATE: 11/06/2024
NARRATIVE
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Regarding the allegations: 1.) Staff did not provide responsible party with a copy of resident's admissions agreement. 2.) Staff did not provide responsible party with a copy of resident's facility file. On 07/11/2023, the Department received a complaint alleging the Licensee failed to provide copies of R1’s documents including admission agreement to R1’s responsible party. Interview with the Licensee confirmed that R1’s responsible person requested R1’s file, however the Licensee attempted to reach out to R1’s responsible person but couldn’t contact them. The Licensee explained that R1’s responsible person moved, and the Licensee no longer has the correct mailing address to send the documents. The Licensee stated that he will attempt further to contact R1’s responsible party to send R1’s file and admission agreement. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230711101116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87506(c)(1)
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87506 Resident Records: (c) All information and records obtained from...(1)The licensee shall be responsible for storing active and inactive records ...This requirement has not been met as evidenced by:
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Licensee stated that requested documents to R1’s responsible party will be provided. The Licensee stated that he will send LPA via email proof that documents were provided.
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Based on interview and records review, the licensee did not comply with the section cited above as R1’s records were not provided to R1’s Responsible Party and/or designated representative 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230711101116

FACILITY NAME:VIP SENIOR LIVING LLCFACILITY NUMBER:
197609827
ADMINISTRATOR:AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:5457 WOODMAN AVETELEPHONE:
(818) 994-4116
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 5DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jeffrey Alvarez, LicenseeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not properly refund responsible party after resident's death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 1:40 p.m., the LPA met with the Licensee and explained the reason for the visit.

During the initial visit conducted on 07/20/2023 between 10:15 a.m. and 12:30 p.m., LPA Peraldi conducted an interview with the Licensee, conducted a physical plant tour and requested copies of pertinent documents during the time of the visit.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230711101116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
VISIT DATE: 11/06/2024
NARRATIVE
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Regarding the allegation: 3.) Staff did not properly refund responsible party after resident's death. On 07/11/2023, the Department received a complaint alleging an incorrect amount of refund after Resident #1’s (R1’s) death was issued to R1's responsible party. Per record review, R1 died on 01/04/2023 and prior to R1’s death, R1’s responsible party paid $3,500 for the time period of 12/07/2022 to 01/07/2023. Per interview with the Licensee, the Licensee stated that he refunded R1’s responsible party for $1,700. The refunded amount is for 01/04/2023 to 01/07/2023 which is less than $1700 given. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5