195850091-5-8-2024-29-AS-KHEN-D5KUFS-20240524153313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 05/08/2024
Date Signed: 05/08/2024 01:05:41 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2024 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240429101753

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	TREVIN R WILLIS		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 45	DATE:	05/08/2024
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Michael Owens, Executive Director		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not adhering to resident's Admission Agreement

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint visit to address the allegation listed above. LPA arrived at 09:26AM and was greeted by front desk staff. Shortly after arrival, LPA met with Executive Director Michael Owens. Entrance interview conducted.

During today’s visit, LPA interviewed Executive Director (ED) at 09:30AM, toured the facility with ED at 10:38AM, and LPA reviewed and obtained copies of pertinent documents. The following was then determined:

The complaint alleges that following Resident #1 (R1)'s death and personal belongings were removed from the facility, no refund was issued to R1's family/estate, per the Admission Agreement. Based on interview and record review, R1 passed away on 12/19/2023. Interview revealed that R1's personal items were removed as of 12/30/2023. Payment for R1's December fees had been paid in full, including both
Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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 29-AS-20240429101753

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: 05/08/2024

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

care fees and base rent. Per R1's Admission Agreement, related to resident death, indicates "within 15 days after your personal property is removed, your estate...will receive a refund of any fees paid in advance covering the period after your personal property has been removed." All parties interviewed were in agreement that R1's personal belongings were removed as of 12/30/2023. Additionally, interview with Executive Director revealed that R1 should not have accrued care fees, as of the date of their death. Instead, only the base rate should have been charged following R1's death to the date their items were removed from the R1's room. Review of R1's Admission Agreement and all attachments, as well as their ledger did show R1 had a carried over credit on their account. Interview revealed that this credit was due to a July 2023 rent concession, which should have been utilized for that month only and not carried over. However, the ledger indicates a credit labeled as "aging 8/2023" and is shown carried over each month R1 resided at the facility. Review of R1's Admission Agreement does not explicitly state this credit does not carry over, and as it does show carried over on R1's ledger, therefore, this amount is also owed to R1's estate. Documents reviewed revealed that Administrator Trevin Willis did request to their corporate office a refund in the amount of $2289.00 most recently on 02/01/2024, however as of today's visit the refund has not been issued. Therefore, based on interview and record review, the allegation that "Facility is not adhering to resident's Admission Agreement" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC 9099-D.)

Exit interview conducted. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20240429101753

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: 05/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/15/2024 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	§1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director sent a new refund request to the Licensee's accounting department during today's visit to request the refund be issued as soon as possible. Executive Director will provide proof to CCL by POC due date of refund issued.
	8 9 10 11 12 13 14	Based on interview and record review, the Licensee did not comply with the above cited section, as R1 passed away and all belongings were removed as of 12/30/2023 and refund has yet to be issued, which poses a potential personal rights risk to residents 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3