195850091-8-17-2022-29-AS-JAPL-CHFV3G-20220819160444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:36:14 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220411133953

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	EILEEN ESQUIVEL		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 17	DATE:	08/17/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator-Eileen Esquivel		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to lack of supervision, R1 sustained facial fractures while in care.
Staff are getting into trouble by management for calling 911.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit today to deliver final findings for the above allegations. The initial complaint visit was conducted on 04/12/2022 by LPA Elsie Campos and a subsequent visit was conducted on 04/16/2022 by LPA Campos and LPA Smith. During today’s visit, LPA Campos met with Administrator Eileen Esquivel and explained the reason for the visit.

Allegation
Neglect/Lack of Supervision: Due to facility neglect/lack of supervision, Resident #1 (R1) sustained facial fractures while in care.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 04/11/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that the facility staff failed to obtain timely medical care for Resident #1 (R1). It was reported that on 04/08/2022 the overnight (NOC) shift witnessed R1 with a nosebleed and a bruise to left eye, yet R1 was not transported to a medical facility until 1:00 p.m. later that day. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Olivia Spindola.

On 04/12/2022, between 10:15 a.m. and 2:15 p.m., LPA Campos conducted the initial 10-day complaint visit. The LPA met with the Administrator Eileen Esquivel and explained the reason for the visit. During the visit there were ten (10) staff and thirteen (13) residents present. The LPA reviewed records and obtained pertinent copies of documents at 11:00 a.m. and 1:40 p.m. From 10:25 a.m. to 12:10 p.m., the LPA conducted a physical plant tour with the Administrator and interviewed staff. The Administrator was notified that the complaint was referred to the Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Olivia Spindola.

On 04/16/2022, LPAs Campos and Ashley Smith conducted an unannounced subsequent complaint visit. The LPAs met with Business Office Manager Megan Cordova and explained the reason for the visit. During the visit, the LPAs conducted a physical plant tour at 1:20 p.m., conducted a file review at 11:00 a.m. and interviewed staff from 11:50 a.m. to 3:49 p.m. The LPAs noted further investigation was required.

Investigator Spindola conducted interviews with the facility Health Services Director on 05/03/2022, at approximately 11:00 a.m.; with the facility Executive Director/Administrator at approximately 12:10 p.m.; with facility caregiver at approximately 12:45 p.m.; with the facility Environmental Services Director at approximately 1:30 p.m.; with a facility resident at approximately 1:50 p.m.; on 05/12/2022 and 06/28/2022 left voice messages for R1’s representative; with R1’s representative on 07/06/2022 at 9:00 a.m.; with facility staff on 07/07/2022 from approximately 12:00 p.m. to 12:30 p.m.; and with facility staff on 07/08/2022 from approximately 10:30 a.m. to 11:30 a.m. Additionally, Investigator Spindola reviewed copies of R1’s facility records, medical records and photos of R1’s injuries.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 was admitted to the facility on 03/23/2022. According to the Physician Report dated 03/22/2022, R1’s primary diagnoses included Dementia and listed R1 as non-ambulatory. R1’s mental condition was noted as confused, disoriented, with inappropriate and aggressive behavior. The report listed no wandering or sundowning behavior. The facility assessment, dated 03/23/2022, noted R1 “had no mobility issues, no known sleep issues, and no known fall risk”. The assessment noted R1 was “mobile and there were no ambulation concerns according to the physician’s assessment and personal assessment”.

The investigation revealed that on 04/08/2022, R1 sustained an unwitnessed fall. Sometime after 2:00 a.m., the overnight (NOC shift) facility caregivers witnessed R1 with a nosebleed and gave R1 an ice pack. When the caregivers asked R1 how R1 injured their face, R1 told them they could not remember. At 4:00 a.m., the caregivers noticed R1’s eye had a small bruise. Staff #1 (S1) then sent a text message to the facility Health Services Director and Administrator. Later that day, R1 was taken to West Hills Hospital and diagnosed with fractures to the nose and left eye orbit.

Based on the fact that the fall was unforeseen, R1 could not remember how they sustained the facial injuries, R1 was no considered a fall risk and no witnesses observed the fall, the allegation “Due to facility neglect/lack of supervision, Resident #1 (R1) sustained facial fractures while in care” is deemed Unsubstantiated at this time.

Allegation: Staff are getting into trouble by management for calling 911

It was alleged that when staff felt that they needed to call 9-1-1 for an emergency, management threatens to fire them. Interviews with staff revealed that they have not been directed or discouraged from calling 9-1-1; rather, staff are encouraged whenever they determine residents are in need of elevated medical assistance to inform the Administrator and or Health Services Director to ensure that all parties are appropriately notified. Interviews further revealed that if there is an emergency situation, staff should call 9-1-1 before informing the administrator or health services director, a delay in calling the administrator first could cause a resident their life. The administrator and health services director were reminded that staff are essential in assessing the resident appropriately and taking on the decision to call 9-1-1 during emergencies. The facility has taken steps to re-train on 9-1-1 protocols. This investigation did not reveal any evidence of “staff getting in trouble by management for calling 9-1-1”; therefore, this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 10

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220411133953

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	EILEEN ESQUIVEL		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 17	DATE:	08/17/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Adminsitrator-Eileen Esquivel		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not obtain medical care in a timely manner.
A supervisior was not available for guidance.
Staff did not notifiy authorized representative of resident injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit today to deliver final findings for the above allegations. The initial complaint visit was conducted on 04/12/2022 by LPA Elsie Campos and a subsequent visit was conducted on 04/16/2022 by LPA Campos and LPA Smith. During today’s visit, LPA Campos met with Administrator Eileen Esquivel and explained the reason for the visit.

Allegation
Neglect/Lack of Supervision: Facility staff failed to obtain timely medical care for Resident #1 (R1).

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed that on 04/08/2022, R1 sustained an unwitnessed fall. Sometime after 2:00 a.m., the overnight (NOC shift) facility caregivers witnessed R1 with a nosebleed and gave R1 an ice pack. When the caregivers asked R1 how R1 injured their face, R1 told them they could not remember. At 4:00 a.m., the caregivers noticed R1’s eye had a small bruise. Staff #1 (S1) immediately left messages via text for the Health Services Director and the Administrator informing them of R1’s injuries and requested approval to send R1 to the hospital; however, they did not respond to the text messages. Between the hours of 7:00 a.m. and 12:00 p.m., caregivers informed the Health Services Director and the Administrator of R1’s serious facial injuries and the need to obtain immediate medical care. At approximately 1:00 p.m., the Health Services Director notified R1’s representative of R1’s need of medical care. R1’s representative agreed to come to the facility and transport R1 to the hospital for medical care. R1’s representative took R1 to West Hills Hospital where R1 was diagnosed with fractures to the nose and left eye orbit.

The Administrator and the Health Services Director did not take action to have R1 transported to a medical facility for more than 8 hours, in spite of several staff informing them of R1’s need for medical care. Therefore, the allegation “Neglect/Lack of Supervision - Facility staff failed to obtain timely medical care for Resident #1 (R1)” is deemed Substantiated at this time.

Allegation
A supervisor was not available for guidance
It was alleged that a supervisor was not available for guidance when staff attempted to contact the supervisors on 4/8/2022 to inform them that a resident #1 (R1) was exhibiting a serious looking injury on their face. Although the allegation is that a supervisor was not available, they were actually asking for an administrator (ED) and or health services director (HSD). It was alleged that on 04/08/2022 the ED and HSD failed to get back to facility staff after staff attempted to contact them at approximately 1:00 a.m. when R1 was observed exiting their bedroom with a bloody nose. Interviews revealed that rather than calling the ED and or the HSD, staff only sent a text message at approximately 4:00 a.m., approximately 45 minutes after R1’s injuries were observed to have worsened. Staff interviews revealed that staff felt that the ED and or HSD are available, as needed; and, that the directive is not only to text but to call when there is an emergency or staff need guidance. Interviews with the ED and HSD revealed that staff did not call but only sent a text.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

However, the ED and HSD failed to respond and no other attempts to seek guidance by staff or call 9-1-1 were attempted therefore R1 was neglected. The HSD was again informed in the morning at approximately 7:00 a.m. that R1 needed assessing. The HSD stated that they would assess R1 upon their arrival, but never did and instead left to take another resident to an appointment while R1 lay in bed. It was not until the HSD’s return to the facility that R1 was assessed.

Based on the fact that the staff did not exhaust all options to contact supervisors regarding R1 upon the discovery of their injuries and supervisors did not return calls or texts timely, the allegation “a supervisor was not available for guidance” is deemed Substantiated at this time.

Allegation
Staff did not notify authorized representative of resident injury.

On 04/11/2022, the Department received a complaint regarding allegations that staff did not notify authorized representative of resident injury. The investigation revealed that on 04/08/2022, R1 sustained an unwitnessed fall. Sometime after 2:00 a.m., the overnight (NOC shift) facility caregivers witnessed R1 with a nosebleed and gave R1 an ice pack. At 4:00 a.m., the caregivers noticed R1’s eye had a small bruise. Staff #1 (S1) immediately left messages via text for the Health Services Director and the Administrator informing them of R1’s injuries and requested approval to send R1 to the hospital; however, they did not respond to the text messages. Between the hours of 7:00 a.m. and 12:00 p.m., caregivers informed the Health Services Director and the Administrator of R1’s serious facial injuries and the need to obtain immediate medical care. Whereas staff believed that the Administrator would contact R1’s representative immediately it was not until approximately 1:00 p.m., that the Health Services Director notified R1’s representative of R1’s need of medical care. R1’s representative agreed to come to the facility and transport R1 to the hospital for medical care and R1’s representative took R1 to West Hills Hospital.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Administrator and the Health Services Director did not act to immediately to inform R1’s authorized representative, in spite of several staff informing them of R1’s injuries in the early hours of the day. Therefore, the allegation that “Staff did not notify authorized representative of resident injury” is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator Eileen Esquivel was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/19/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) Incidental Medical and Dental Care.(a) A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall...assist in... medical...care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 8/19/2022
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above. The Administrator and the Health Services Director did not take action to have R1 transported to a medical facility timely which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)
Type A 08/19/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident... When changes... are observed... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	1. Licensee with submit plan on how they will ensure residents reporting parties are notified of changes. 2. Review regualtion 87211 reporting requirements with management and submit to CCL no later than 8/19/22.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews the licensee failed to notify R1's responsible party of R1's change in condition immediatley upon discovery, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC9099 (FAS) - (06/04)

Page: 10 of 10

Control Number 29-AS-20220411133953

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/19/2022 Section Cited CCR 87405	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a)... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility...	1 2 3 4 5 6 7	The licensee will submit a plan on supervisor coverage and develop a schedule to ensure appropriate supervisory coverage is maintained 24/7 and provide proof to CCL no later than 8/19/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews an administrator was not available for immediate guidance during incident on 4/8/2022 which poses an immediate health and saftey risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC9099 (FAS) - (06/04)

Page: 9 of 10