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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610292
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:56:37 PM

Substantiated


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
11/01/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20241101125517
FACILITY NAME:ARDENT MANORFACILITY NUMBER:
197610292
ADMINISTRATOR:DE GUZMAN, ROILANN CYELLFACILITY TYPE:
740
ADDRESS:22604 PAMPLICO DRIVETELEPHONE:
(213) 804-5665
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 6DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Roilann De GuzmanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide records to resident's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analysts Abeye Duguma and Angelica Segovia conducted an unannounced initial complaint visit to the facility. Upon arrival LPAs met Roilann De Guzman and explained the reason for the visit.

--- Staff did not provide records to resident's authorized representative.

It was alleged that requests started in May 2024 and to this day requesting party has not received all documents. To investigate the allegation, on 11/07/2024 at around 10:00a.m. LPA conducted interviews with other parties, requested records at around 11:00a.m. and interviewed the administrator Roiland De Guzman from around 11:15a.m. to 11:45a.m. During interviews with other parties, they stated ALL records were requested on 05/14/2024 and 10/04/2024 however facility only sent partial documents such as Physician’s Report, Care Plan and Admission’s Agreement.

(CONT. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 3
Control Number 31-AS-20241101125517
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: ARDENT MANOR
FACILITY NUMBER: 197610292
VISIT DATE: 11/07/2024
NARRATIVE
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A review of records revealed that requesting party sent legal power of attorney documentation and a letter requesting ALL documents on 05/14/2024 and 10/04/2024. A review of facility records revealed facility was in possession of other documents that were NOT sent such as Consent Forms, Personal Rights, Centrally Stored Medication Destruction Record and I.D. and Emergency Information. During interview with the Administrator, they confirmed that only the Physician’s Report, Care Plan and Admission’s Agreement were sent to the requesting party and did not know they were supposed to send other documents in their possession.

Based on interviews and record review, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241101125517
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: ARDENT MANOR
FACILITY NUMBER: 197610292
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2024
Section Cited
CCR
87468.2(a)(19)
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87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities-To have prompt access to review all of their records and....shall be provided within two (2) business days…This requirement is not met as evidenced by:
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The Administrator will review regulation 87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities and submit a written statement ensuring that they will adhere them and submit all missing documents to the responsible party by the POC due date.
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Based on interviews and record review, the licensee did not ensure all records were provided to the responsible party which poses a potential personal right violation 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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3