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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610191
Report Date: 11/21/2023
Date Signed: 11/21/2023 12:17:15 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
11/16/2023 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20231116114248
FACILITY NAME:GARDENS AT NORTHRIDGE, THEFACILITY NUMBER:
197610191
ADMINISTRATOR:GENA GRUNDEISFACILITY TYPE:
741
ADDRESS:17650 WEST DEVONSHIRE STREETTELEPHONE:
(818) 886-1616
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:135CENSUS: 78DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christina Spears, Executive Director TIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Facility is not recognizing resident's current Power of Attorney status
INVESTIGATION FINDINGS:
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At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina, and Gina Saucedo conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with the Executive Director and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:05am, LPAs requested resident and staff roster. At 10:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, R1’s notarized Power of Attorney (POA) etc., relevant to the investigation. At approximately 10:15am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:30am – 11:30am, LPAs interviewed the Executive Director, Resident Service Director and Resident #1 (R1).
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
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-20231116114248
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: GARDENS AT NORTHRIDGE, THE
FACILITY NUMBER: 197610191
VISIT DATE: 11/21/2023
NARRATIVE
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It was alleged that the Facility is not recognizing resident's current Power of Attorney (POA) status and R1 is being placed in a Memory Care Unit against his/her will. To investigate this allegation, LPAs conducted review of R1’s Power of Attorney (signed and dated on 09/09/2002) and a Physician’s Report (signed and dated on 04/27/2023). Review of R1's Physician's Report indicated that R1 is diagnosed with Dementia and can not leave unassisted. Interview with the Executive Director and Resident Service Director revealed that upon admission, the facility will assess the resident and review their Physician's Report in order to determine if the resident will be placed in a Memory Care Unit or Assisted Living. In addition, interview with the Executive Director and Resident Services Director revealed that upon admission the resident/family/conservator will provide the facility with any legal documents (if any) the facility always recognizes residents POA’s/Conservator, etc. and when a copy is provided, the facility files the document in resident’s individual files. Lastly, LPAs attempted to conduct an interview with R1, but due to R1's medical condition LPAs were unable to receive necessary information. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time.


Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2