197608694-5-6-2026-29-AS-KLOZ-DVHP9S-20260629110737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 05/06/2026
Date Signed: 05/06/2026 04:24:40 PM

Unsubstantiated

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
01/15/2026 and conducted by Evaluator Trevor Byrne

COMPLAINT CONTROL NUMBER: 29-AS-20260115163431

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	GRACE HARTNETT		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	179	CENSUS: 163	DATE:	05/06/2026
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Justine Ortiz		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not respond to residents’ requests for assistance in a timely manner.
Staff did not provide residents with adequate food service.
Facility does not have adequate activities for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Trevor Byrne conducted a follow-up complaint visit for the above allegations. LPA arrived to the facility at 09:56 AM. LPA met with Interim Executive Director Justine Ortiz (ED-I). Entrance interview conducted and the reason for the visit was explained.

During today’s visit, the LPA conducted a brief physical plant tour, conducted a file review for one (1) resident, collected copies of pertinent documentation, interviewed the ED-I, interim Director of Assisted Living (MC) Yasmin Hernandez, two (2) staff members, and one (1) resident between approximately 10:00 AM and 03:30 PM.

CONTINUED ON LIC 9099C.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

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 29-AS-20260115163431

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 05/06/2026

NARRATIVE

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The allegation of “Staff did not respond to residents’ requests for assistance in a timely manner.” alleges that facility residents who press their call button have to wait an unacceptable amount of time for facility staff to respond to their requests for assistance. Throughout the investigation of this complaint LPAs Byrne and Cortez interviewed twelve (12) randomly selected residents of the facility. Eleven (11) residents interviewed did not express concerns with the amount of time it takes facility staff to respond to resident’s requests. Residents reported that staff have responded to a pendant press within as little as five (5) minutes but often within 10-15 minutes. LPA Byrne conducted unannounced tests of the signal alert system in four (4) resident units across multiple days of inspection. LPA received responses from the pendant presses that ranged from no less than four (4) minutes to no more than twenty-two (22) minutes. LPA interviewed ED-I who stated that the facility aims for a response time of no more than twenty (20) minutes. LPA observed the facility’s call button response logs from January 2026 - February 2026 and observed an average response time of approximately five (5) minutes. Of two hundred and fifty six (256) call responses in January and two hundred forty seven (247) call responses in February only sixteen (16) exceeded the facility's expected response time of twenty (20) minutes (Excluding outliers where the system was turned into the front desk for battery replacement and the call was not cleared on the system). Of those sixteen (16) only nine (9) response times exceeded twenty five (25) minutes. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not respond to residents’ requests for assistance in a timely manner.” Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Staff did not provide residents with adequate food service.” alleges that the food served to residents is not good quality and the facility runs out of some meals to provide residents. LPA Byrne conducted a physical plant tour of the facility and observed the facility to have a sufficient supply of two (2) days perishable and seven (7) days non-perishable foods. LPA interviewed facility staff including the Director of Dining, a Sous Chef, and a Server. Staff interviewed stated that the facility offers an “Everyday menu” and a “Specials menu” for each meal service. Staff explained that the facility stocks approximately 200 portions of the items listed on the specials menu for each dining service as not every resident orders meals off of the specials menu. Staff stated that specials are changed daily and are offered on a first come first serve basis. Staff stated that once they run out of portions no additional special items are offered for the meal service. Staff reported that items on the everyday menu are always available for residents to order if the special items run out. Interviews with staff and residents revealed that there have been times where the food that is ordered takes longer than normal to be served to the residents and due to this delay residents were served cold meals. CONTINUED ON LIC 9099C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260115163431

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 05/06/2026

NARRATIVE

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Residents interviewed stated that if notified staff will take the meal back to warm it up or will remake the meal. Staff interviewed confirmed that at resident’s request meals are reheated and denied ever refusing to reheat or remake a resident’s meal. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not provide residents with adequate food service.” Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Facility does not have adequate activities for residents.” alleges that the facility has inadequate activities on the weekends, inadequate exercise activities, and activities that are not challenging/stimulating for residents. Throughout the investigation LPA interviewed twelve (12) residents. Residents interviewed who participated in activities did not have concerns about the amount of activities offered or the quality of the activities. Residents informed LPA that the facility offers a wide variety of activities and residents lead some of the activity groups offered. LPA interviewed staff members who participated in facilitating resident activities. Staff stated that the facility offers a wide variety of activities for residents to participate in. Staff provided examples of activities including: creative writing, improve classes, poetry, grief and loss support, painting, gardening, a men’s club, elders alliance, live music, bingo, charades, misc. games, etc. LPA observed the facility’s activity calendar across multiple days of inspection and observed an average of four (4) exercise (body) activities, four (4) mind activities, one (1) music (Comfort) activity, five (5) social (Connection) activities, and four (4) creative activities offered on a daily basis. LPA interviewed Executive Director (ED) Grace Hartnett who informed LPA that the facility had let go of their previous fitness director in November of 2025 but the facility was in the process of interviewing individuals to fill the role. LPA interviewed ED-I who informed LPA that a new Fitness Director was hired on 02/11/2026. ED-I denied any resident complaints about the new Fitness Director. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Facility does not have adequate activities for residents.” Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC9099 (FAS) - (06/04)

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