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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850240
Report Date: 12/27/2023
Date Signed: 12/27/2023 12:23:45 PM


Document Has Been Signed on 12/27/2023 12:23 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VARIEL OF WOODLAND HILLS, THEFACILITY NUMBER:
195850240
ADMINISTRATOR:JOYCE AQUINOFACILITY TYPE:
740
ADDRESS:6233 VARIEL AVETELEPHONE:
(818) 651-6018
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:436CENSUS: 327DATE:
12/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Joyce AquinoTIME COMPLETED:
12:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident and suspected abuse report. LPA met with Administrator Joyce Aquino. LPA explained the reason for today's visit. Entrance interview conducted.

Previously, on 12/19/2023, on duty LPA Emily Peraldi received a telephone call from the Administrator indicating an alleged incident had been reported to the facility Management involving Staff #1 (S1) inappropriately waking up Resident #1 (R1). Administrator indicated a suspected abuse report would be sent to the Woodland Hills Regional Office the following day. LPA Dulek then reviewed the document, which indicates that on 12/16/2023, S1 told Staff #2 (S2) to wake up R1 by pinching R1's nipples. Administrator indicated the facility is conducting an internal investigation and S1 is suspended during the investigation. Administrator sent photos to LPA Peraldi of R1's chest area, which did show bi-lateral bruising.

During today's visit, LPA interviewed Administrator and Director of Compliance at 09:55AM, toured the facility with Director of Compliance at 10:06AM, LPA gathered and reviewed copies of pertinent documents and interviewed staff between 10:38AM and 11:45AM.

Record review revealed that R1 resides in the facility's Memory Care unit and requires assistance with most ADLs, including grooming, hygiene, transfers and escorts. Interviews revealed that R1 is tired frequently, most often after meals, R1's family prefers they not rest sometimes, and that R1 can be difficult to arouse when in a deeper sleep. Interviews and written staff statements obtained during the facility's internal investigation did indicate staff have been told by S1 that S1 has awoken R1 by pinching R1's nipples and had instructed other staff to do the same when they are having difficulty waking up R1. Multiple staff reported being aware of this statement made by S1. Photographs of R1's chest area showed bruising on both sides of R1's chest, near their nipples, which appears consistent with pinching.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).
Exit interview conducted. Copy of report and appeal rights were reviewed and issued during today's visit.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/27/2023 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: VARIEL OF WOODLAND HILLS, THE
FACILITY NUMBER: 195850240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2024
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
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Administrator indicated that S1 is not currently working, pending results of the investigation. Remaining staff were trained on 12/20/2023 on Resident Personal Rights and putting residents to sleep in their beds. Administrator will follow up with CCL by POC due date related to the employment status
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Based on interview, review of witness statements and bruising observed on R1, S1 reportedly pinched R1's nipples to awaken R1, which poses an immediate health, safety, and personal rights risk to residents in care.
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of S1.

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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
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