197603296-11-11-2020-31-AS-CHAS-BX3VDA-20210108152025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603296
Report Date: 11/11/2020
Date Signed: 11/11/2020 02:27:04 PM

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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2020 and conducted by Evaluator Wendell Smith

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20201007151037

FACILITY NAME:	FAIRWINDS - WEST HILLS		FACILITY NUMBER:	197603296
ADMINISTRATOR:	ELVIS GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	8138 WOODLAKE AVE		TELEPHONE:	(818) 713-0900
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY:	130	CENSUS: 95	DATE:	11/11/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Elvis Gutierrez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident fell while in care sustaining minor bruises

Staff did not seek medical treatment for resident

Resident not treated with dignity

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Wendell Smith initiated a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted through the telephone with Elvis Gutierrez.
Resident fell while in care sustaining minor bruises
It is alleged that resident #1 (R1) sustained a fall in care and had minor bruises. LPA conducted interviews with R1 and facility staff. LPA also obtained copies of R1's care plan and other related documentation. Information revealed that on 4/15/2020 R1 sustained a fall in their room after tripping over their own feet while getting up. R1 has a walker and did not use their walker in this incident. After R1 fell they used their pendant to ask for assistance. Facility staff responded and assisted R1 up and an assessment was performed on R1. Based on information obtained through interviews and reviewing R1's assessment R1's fall was not caused by any facility negligence. Based upon the information obtained this allegation is deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2020

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 2

Control Number 31-AS-20201007151037

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIRWINDS - WEST HILLS	FACILITY NUMBER: 197603296
	VISIT DATE: 11/11/2020

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

Staff did not seek medical treatment for resident
It is alleged that after R1 had their fall facility did not seek medical treatment for R1. LPA conducted interviews with R1 and facility staff. LPA obtained the facility incident report regarding the fall. Information from interviews revealed that after R1 was assisted up R1 was able to walk by themselves, had her vital signs checked, and facility observed R1 for any changes. R1 is also mentally alert and able to make the decision if they needed to have emergency services. Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time.

Resident not treated with dignity
It is alleged that R1 asked facility for permission to have their friend come over and pack due to them moving and facility did not respond to R1 in a timely manner. LPA interviewed R1 and the administrator regarding this allegation. Information revealed that R1 did ask administrator for permission for a friend to come into the building to assist with moving. R1 asked the administrator in the morning and by that afternoon the administrator responded that same afternoon. Based on the information obtained this allegation is deemed Unsubstantiated at this time. R1 did not have to wait for a long period of time to get an answer to their question.
Exit Interview conducted. Copy of report emailed to administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2