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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850240
Report Date: 09/28/2023
Date Signed: 09/28/2023 11:13:56 AM


Document Has Been Signed on 09/28/2023 11:13 AM - 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: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: 287DATE:
09/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Joyce AquinoTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident visit to the facility. The LPA was greeted by Administrator Joyce Aquino and informed them of the reason for the visit. The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/17/2023.

The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 9/17/2023 regarding Resident #1 (R1) and two staff (S1, S2). It was documented that at approximately at 1:15 a.m on 9/17/2023, S1 was observed by S2 removing R1's sweater in a rough manner, pulling/gripping R1's arms trying to lay R1 on their bed. It was further reported that when a Wellness Nurse went to check on R1, R1 stated "Are you going to hit me too?" A Wellness Nurse completed a skin assessment of R1's body and noted redness on her arm.

During todays visit, the LPA conducted four (4) staff interviews, three were conducted via telephone call, obtained pertinent records and interviewed the administrator throughout the visit. Staff interviews revealed that R1 was heard screaming by three staff (S2, S3, S4), which was stated to be unusual behavior for this resident and cause staff to be concern and run to check on R1. S1 was observed by S2, forcefully gripping R1 to remove their sweater, and forcefully sitting R1. Staff interviews further revealed that R1 was observed crying after the incident by S5, and staff ensure to not leave R1 alone with S1 for the remainder of the night. Documents obtained revealed that R1 had been assesses by AM wellness nurse with redness/bruises on their left arm, however Administrator stated they were unsure if they were new or old as R1 had a fall on 9/14/23.

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 issued at the time of the visit.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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Document Has Been Signed on 09/28/2023 11:13 AM - 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
WOODLAND HILLS N.ASC, 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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2023
Section Cited
CCR
87468.1(a)(3)

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87468.1Personal 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 evidence by:
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Plan of correction has been met as S1 is no longer working at the facility.
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Based on Records obtained. The licensee did not comply with the above cited section as S1 was observed forcefully gripping and forcefully sitting R1 which poses an immidiate 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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