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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 08/21/2024
Date Signed: 08/21/2024 04:06:18 PM


Document Has Been Signed on 08/21/2024 04:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:MICHAEL OWENSFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 40DATE:
08/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Trevin WillisTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management visit at 02:20PM. The purpose of this visit is to conduct an investigation regarding two self-reported incidents and SOC 341s that occurred on unknown dates. Upon arrival, the LPA met with Executive Director (ED) Trevin Willis and explained the reason for the visit. Entrance Interview conducted.

On 08/17/2024, the Department received an incident report stating that on an unknown date, two (2) staff members, Staff 1 (S1) and Staff 2 (S2), were witnessed by Staff 3 (S3) slapping Resident 1 (R1) across the face in R1’s bedroom. According to the report, the incident occurred weeks ago and was reported to the previous ED Michael Owens and Health and Services Director Gloria Barron, but no action was taken at the time. S3 reported the incident to Staff 5 (S5) who reported to ED Willis on 08/16/2024. S1 and S2 have been placed on leave until a formal investigation can be completed by company HR. Families have been notified.

The Department received another incident report on 08/20/2024 stating that on an unknown date, S1, S3, and Staff 4 (S4) took a selfie in front of Resident 2 (R2) in the bathroom who was exposed in the picture. Staff members then shared the picture among their personal circles. Staff 6 (S6) reported the incident to ED on 08/20/2024. S1, S2, S3, and S4 have been placed on leave until a formal investigation can be completed by company HR. Families were notified to call ED.

During today’s visit, LPA Barutyan conducted interviews with the ED and three (3) staff members between 02:25PM-03:53PM, conducted a file review at 03:00PM, and obtained copies of pertinent documents relevant to the investigation.

Prior to issuing final licensing report, it has been determined that further investigation is needed at this time.



Exit Interview Conducted and Report was Issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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