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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850240
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:17:43 PM


Document Has Been Signed on 07/07/2023 01:17 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: 254DATE:
07/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Joyce AquinoTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Incident visit to the above facility. LPA Ascencio met with Administrator/Director of Resident Care Services (DRCS) Joyce Aquino at 09:25 a.m.

On 07/06/02023, LPA Ascencio received a call from DRCS Aquino, at 06:03 p.m. regarding an incident that occurred on 07/05/2023, between a Memory Care resident, Resident #1 (R1), Staff #1(S1) and S2. Additionally, DRCS Aquino submitted an Unusual Incident Report and a SOC 341 Elder Abuse Report to Community Care Licensing (CCL), Adult Protective Services (APS), Long Term Care Ombudsman (LTCO) and Local Authorities.

Per reports, on 07/05/2023, at approximately 09:30 p.m., R1 was being assisted with toileting needs by S1, S2 and S3. During this time, R1 was resisting and refusing toileting assistance, S1 proceeded to grab the soiled adult brief from the trash can, wave it at a very close proximity at R1's face and began to tell R1 " Look, this is what we just took off from you." S1 and S2 began to laugh at the situation while R1 moved their face away from the soiled adult brief yelling "Stop." Because S3 witnessed the actions of S1, S3 communicated the events to their direct supervisor the follow day on 07/06/2023.

During today's visit, DRCS Aquino provided LPA Ascencio with written statement from S1, S2 and S3 confirming and admitting what happened the night of 07/05/2023. Interviews with S1, S2 and S3 could not be conducted as staff members are currently placed on a temporary suspension pending an internal investigations. Later that same day, an attempted interview with R1 was conducted at 10:43 a.m. R1 is a Memory Care resident with a Diagnosis of Parkinson's and Dementia. R1 could not recall incident on 07/05/2023.

Continued on LIC 809 - C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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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
VISIT DATE: 07/07/2023
NARRATIVE
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Additional interviews with Memory Care residents indicated that the caregivers are nice, professional and that they have not have any problems, while interviews with staff members indicated the process of how to report abuse if observed.

1 citation was issued during today's visit. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

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

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2023 01:17 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: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
87468(a)(1)

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87468.1(a)(1) Personal Rights of Residents in All Facilities. Residents ... shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Administrator will conduct all staff training on Mandated Reporting, Elder Abuse, Code of Conduct, Resident Rights, and Dementia related behaviors. Administrator will submit all documentation to CCL by 07/21/2023.
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Based on interviews and written statements, the licensee did not comply with the section cited above as S1 humiliated R1 by waving a soiled adult brief in R1's face, which poses a potential personal rights 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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