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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605820
Report Date: 03/17/2020
Date Signed: 10/07/2020 04:12:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNRISE OF WESTLAKE VILLAGEFACILITY NUMBER:
197605820
ADMINISTRATOR:HOWELL, ZACHARYFACILITY TYPE:
740
ADDRESS:3101 TOWNSGATE RDTELEPHONE:
(805) 557-1100
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91361
CAPACITY:124CENSUS: 82DATE:
03/17/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Zak Howell, Executive DirectorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a tele-case management visit with Sunrise of Westlake Village at 805-557-1100 at 9:23 a.m. due to an incident report that was received via fax on 03/13/2020. The LPA spoke with Executive Director Zak Howell on the phone and explained the nature of the tele-visit.

The Regional Office received an incident report indicating that Resident #1 (R1) had an unwitnessed fall on 2/27/2020, where as a result, R1 sustained a broken hip, broken shoulder, and broken arm, as well as a brain bleed. The Regional Office also received a death report via fax on 3/13/2020 indicating R1 had passed away on 3/1/2020 due to a brain bleed.

During the telephone call on 03/17/2020 at 9:23 a.m. with the Executive Director, the LPA requested the following documents to be sent via email for R1: Needs and Service Appraisal, Physician’s Report, and Identification and Emergency Information, as well as a death certificate. The LPA then conducted a telephone interview with the Memory Care Director along with the Executive Director present at 12:09 p.m.

The LPA has determined that further investigation is needed and will return or call at a later date to continue the investigation. Concerns identified during the tele-visit will be addressed at a later date.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2020
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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