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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 03/29/2024
Date Signed: 03/29/2024 11:39:47 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230811115447
FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:TREVIN R WILLISFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 43DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Michael Owens, Acting Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff failed to report incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit regarding above noted allegation. Reason for the visit is to deliver the investigation finding. Upon arrival LPA met with staff who then contacted designated staff in charge. Executive Director Trevin Willis was not available during todays visit. Reason for visit was discussed with Michael Owen, Acting Executive Director.

Following is a summary of the investigation:

On 8/11/2023, the Department received information that facility manager/administrator did not follow reporting requirements upon haveing knowledge of an alleged sexual assault happening sometime around 7/2022. It was alleged that, although the former Administrator Eileen Esquivel was informed about two staff allegedly sexually assaulting resident #1 (R1), the former Administrator did not follow through to report to Community Care Licensing as mandate through with reporting requirements by submitting a Special Incident Report (SIR) to the Licensing Office as required; nor did they submit a SOC341 for suspected abuse. (Cont.)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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-20230811115447
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: 03/29/2024
NARRATIVE
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Records reviewed and interview conducted with staff on 08/14/2023 from approximately 10:05am-11:45am, confirmed that above alleged incident was not reported.

Therefore, based on the information obtained during this investigation, there is sufficient evidence to support the claim that staff failed to follow through with alleged investigation in timely manner. This allegation is Substantiated at this time.

Pursuant to Title 22, California Code of Regulation, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted. Appeal rights provided. Copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230811115447
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: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
87211
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(a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency within 7 days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:
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Former Administrator was terminated. The current Administrator shall do the following:
1.Administrator to review Regulation 87211 and Mandated Reporting requirements and submit Statement of Understanding.
2. Provide in-service to all staff on Mandated reporting requirements.
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Based on interviews and record review, facility's former Administrator was aware of the alleged sexual assault R1 made and failed to notify CCLD and follow mandated reporting requirements. This posed an immediate 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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
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
08/11/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230811115447

FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:TREVIN R WILLISFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 43DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Michael Owens, Acting Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff sexually assaulted resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver the investigation finding for the above allegations. Upon arrival LPA met with Michael Owens, Acting Executive Director and explained the reason for the visit.

On 8/11/2023, the Woodland Hills Adult and Senior Care Regional Office (RO) received a complaint alleging prior Resident #1 (R1) was sexually assaulted by two (2) facility staff while in care at this facility. The case was referred Community Care Licensing Division’s Investigation Branch (IB) and was assigned to Special Investigator Douglas Real to interview facility staff, resident and other potential witnesses.
Following is a summary of the investigation finding:
On 08/14/2023, from approximately 10 a.m. to 11:45 a.m., LPA conducted the initial complaint visit. During the visit, LPA interviewed staff, reviewed and obtained records pertinent to the allegations.

Regarding allegation – Resident #1 (R1) was assaulted in the shower by two facility staff: (Cont..LIC9099c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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-20230811115447
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: 03/29/2024
NARRATIVE
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On 08/16/2023, from approximately 1:55 p.m.-2:45 p.m., IB Investigator Douglas Real interviewed facility Administrator and the two (2) staff. On 08/17/2023 at approximately 2:20 p.m., IB Investigator Douglas Real interviewed R1’s responsible party. R1 passed away on 06/24/2023 and was not interviewed.

Staff interview revealed that sometime in November 2022 the facility was notified by R1’s family that R1 had reported being sexually assaulted by two (2) male facility employees while being showered. The facility director at the time was Ilene Owens and she investigated the matter and interviewed the staff. The staff denied the allegation, and nothing was uncovered suggesting there was any merit to the allegation. Staff reported that R1 had dementia, was combative on occasion, and did not like to bathe or shower. R1 frequently needed two-person assistance, especially with showers. Staff reported that R1 dementia was bad, and R1 was often confused. Staff denied the allegation.

Interview with the R1 responsible person (RP) revealed that R1 had dementia and was frequently confused. R1 did not like showering or bathing but needed to be cleaned. It took two (2) caregivers to shower R1 and it was very difficult getting R1 to shower. Sometime in November 2022, R1 was showered by two (2) staff, and R1 claimed staff raped R1. RP stated that they had known the two staff as they had worked with the R1 at another facility, and they had always provided a good level of care. R1 had never made an allegation like that before. After the allegation, they took R1 to be checked by a doctor at an urgent care and the doctor found no evidence of a sexual assault. According to RP, the facility Administrator at the time was notified of the allegation and investigated the allegation. Staff were questioned and the staff denied the allegation. RP saw nothing at the time to suggest the R1 had been assaulted and RP does not believe that R1 was raped.
Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Resident was sexually assaulted by staff” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5