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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603296
Report Date: 08/14/2024
Date Signed: 08/14/2024 11:32:02 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
05/06/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240506163316
FACILITY NAME:FAIRWINDS - WEST HILLSFACILITY NUMBER:
197603296
ADMINISTRATOR:ELVIS GUTIERREZFACILITY TYPE:
740
ADDRESS:8138 WOODLAKE AVETELEPHONE:
(818) 713-0900
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:130CENSUS: 112DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Elvis Gutierrez- Executive DirectorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Admission Agreement was inappropraitly completed.
INVESTIGATION FINDINGS:
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On 8.14.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Elvis Gutierrez who is the Executive Director (ED) of the facility.

An entrance interview was conducted.

At 10 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation: Admission Agreement was inappropriately completed.

It was alleged that the facility’s Admission Agreement was inappropriately completed.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
05/06/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240506163316

FACILITY NAME:FAIRWINDS - WEST HILLSFACILITY NUMBER:
197603296
ADMINISTRATOR:ELVIS GUTIERREZFACILITY TYPE:
740
ADDRESS:8138 WOODLAKE AVETELEPHONE:
(818) 713-0900
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:130CENSUS: 112DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Elvis Gutierrez- Executive DirectorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Inappropriate, exploitive increase in cost for services
Staff did not follow physician's instruction for prescribed medications
Staff interefered with the resident's sleeping/bed time.
Staff isolated resdient
INVESTIGATION FINDINGS:
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On 8.14.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Elvis Gutierrez who is the Executive Director (ED) of the facility.

An entrance interview was conducted.

At 10 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation #1: Inappropriate, exploitive increase in cost for services

It was alleged that the facility inappropriate, exploitive increase in cost for services by 400%. To investigate this allegation, LPA reviewed records and it was found that R1 had been assessed yearly by the wellness director and cost was not submitted to billing. Continie to LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20240506163316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAIRWINDS - WEST HILLS
FACILITY NUMBER: 197603296
VISIT DATE: 08/14/2024
NARRATIVE
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R1 is getting all the additional care that is needed to be provided by the facility when assess by the wellness director yearly. Regarding the increased costs of service, ED has been trying to negotiate a price increase with the reporting party since November of 2023 and the family refuses to accept the increased amount regarding board and care. According to the facility program and record review, ED has been following the 60-day advance notice for a fee increase. Interview sixteen (16) residents out of one hundred seven (107) residents at the facility regarding the above statement are untrue, ten (10) out of sixteen (16) residents expressed no concern regarding this allegation.

Based on the information received and record review this allegation is unsubstantiated this time.

Allegation #3: The staff did not follow the physician's instructions for prescribed medications.

It was alleged that staff did not follow the physician's instructions for prescribed medications. To investigate this investigation, LPA reviewed the Centrally Store Medication Destruction Record (CSMDR) and Medication Administration Record (MAR) of R1. All staff (S1, S2, S3 and, S4) stated that R1 always received their medication as prescribed but resident has a history of refusing their medication and they can’t force the resident to take it. LPA reviewed the Medication Administration Record (MAR) and observed that from February 2023 to July 2023 and from April 2024 to May 2024 the resident medication was given in a timely manner and R1 refused to take their medication occasionally. LPA interviewed sixteen (16) residents about the allegation, and ten (10) out of sixteen (16) residents revealed that it was untrue. Residents stated that they always get their medication as prescribed by their physician and that the staff gives it to them at the correct times.

Based on the information received and reviewed this allegation is Unsubstantiated this time.

Allegation #4: Staff interfered with the resident's sleeping/bedtime.

It was alleged that staff interfered with the resident's sleeping/bedtime. It was alleged that medication was given at an inappropriate time causing R1 circadian rhythm to be interfered. To investigate this allegation, LPA interviewed five (5) out of sixty-five (65) staff and sixteen (16) out of one hundred seven (107) residents. Continue to LIC 9099-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20240506163316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAIRWINDS - WEST HILLS
FACILITY NUMBER: 197603296
VISIT DATE: 08/14/2024
NARRATIVE
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LPA did a record review, and R1 has no medical note from a Primary Care Physician (PCP), sleep specialist, or neurologist to state that medications given at a different time from July of 2023 would cause R1 to have a circadian rhythm. According to interviews with staff, they will only help residents to sleep at night or wake them up at a certain time in the morning when requested to go out with family or doctor appointment. According to interviews with residents, they have no issues with sleeping/ bedtime, residents go to sleep and wake up when they want.

Based on the information received this allegation is Unsubstantiated at this time.

Allegation #5: Staff isolated resident

It was alleged that staff isolated the resident. Staff would leave R1 on their sofa instead of their recliner in bedroom #118. When sitting on the sofa, R1 has a hard time getting up, compared to sitting on the recliner, where R1 can just maneuver from the recliner to their walker to roam the facility independently.

To investigate this allegation, LPA reviewed incident reports and interviewed five (5) out of sixty-five (65) staff and sixteen (16) out of one hundred seven (107) residents. LPA found out that R1 needs assistance while walking with their walker and transferring. R1 is at high risk of falling by themselves when transferring and roaming the facility, there are four (4) incident reports: 10.8.2023, 10.21.2023, 11.15.2023, and 2.10.2024 where R1 had fallen. R1 has been advised repeatedly to use the call button for staff assistance for transfer. During the interview ten (10) out of sixteen (16) residents revealed that staff would not isolate them, they have all the freedom to do activities and roam around the facility.

Based on the information received this allegation is Unsubstantiated at this time.

An exit interview was conducted with Elvis Gutierrez, executive director (ED), and a hard copy of this report was provided.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20240506163316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAIRWINDS - WEST HILLS
FACILITY NUMBER: 197603296
VISIT DATE: 08/14/2024
NARRATIVE
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It was alleged that resident #1 (R1) admission agreement addendum M was incomplete and added by the facility. To investigate the allegations above, LPA conducted an initial visit on 5.15.2024. LPA toured the facility and requested and reviewed the physician's report, staff roster, resident roster, admissions agreement of R1, appraisals, and incident reports. LPA interviewed staff and residents, five (5) out of sixty-five (65) staff and sixteen (16) out of one hundred seven (107) residents. The interview with the executive director (ED) and residents regarding the above statement is untrue, and all residents expressed no concern regarding this allegation.

Upon reviewing admission agreement records obtained from the reporting party (RP) and records from the facility. According to the ED, no residents can be admitted to the facility without signing all necessary documents. LPA reviewed sixteen (16) other residents' records and all their admission agreements were signed but incomplete on addendum A that has the total cost of monthly fee. All the residents admissions agreement was not filled in appropriately, according to page 13 (addendum A Monthly fee), total costs indicate only the monthly payment, which was incomplete. ED did not indicate additional ‘Monthly Service Agreement Summary Charges (addendum M) as requested on page 13 under ‘additional services’. Therefore, aside from the monthly charges indicated on page 13, ED is then requesting another fee for monthly service fee from addendum M from addendum M.

Based on the information and record review received this allegation is substantiated this time.

Deficiency will be cited on LIC 9099-D. Exit interview conducted, a copy of this report was given to ED.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20240506163316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIRWINDS - WEST HILLS
FACILITY NUMBER: 197603296
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2024
Section Cited
CCR
87507(g)(a)(1)
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87507(g)(a)Admission agreements shall specify the following: (1) A comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board, and other items and services shall be listed.
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The ED will submit in writing to RO by 8/28/24, how they will ensure that all residents in care have a proper signed admission agreement.
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This requirement was not met as evidenced by: Based on interviews and document review facility did not indicate the correct total amount for monthly fee on their admission agreement paperwork which poses an potential health and
safety risk or personal rights 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6