197606220-3-22-2023-31-AS-NMAN-CUXTZJ-20230822151026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606220
Report Date: 03/22/2023
Date Signed: 03/22/2023 10:04:37 AM

Substantiated

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
03/13/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230313085609

FACILITY NAME:	WOODLAND WEST HOMES III		FACILITY NUMBER:	197606220
ADMINISTRATOR:	BOZENA KOZBIAL		FACILITY TYPE:	740
ADDRESS:	22537 MARLIN PLACE		TELEPHONE:	(818) 594-7294
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 2	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Angela Anastasi		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Staff did not follow proper COVID-19 mask guidance

INVESTIGATION FINDINGS:

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At 8:45 a.m. on 03/22/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility at 8:55 a.m. inside and out. No immediate health or safety concerns were observed.

Regarding the allegation above, it was alleged Staff #1 (S1) was not wearing a mask. A credible source observed S1 without a surgical mask with residents in care. At 8:50 a.m. LPA observed 1 out of 2 staff wearing a mask during today’s visit. Staff #2 (S2) put on a mask after a brief discussion of infection control policies. Based on interviews and observations of the credible source and LPA, the allegation above is deemed SUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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 4

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
03/13/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230313085609

FACILITY NAME:	WOODLAND WEST HOMES III		FACILITY NUMBER:	197606220
ADMINISTRATOR:	BOZENA KOZBIAL		FACILITY TYPE:	740
ADDRESS:	22537 MARLIN PLACE		TELEPHONE:	(818) 594-7294
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 2	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Angela Anastasi		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Items that could constitute a danger to the residents are not properly stored
Resident's door was not kept free of obstructions

INVESTIGATION FINDINGS:

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At 8:45 a.m. on 03/22/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility at 8:55 a.m. inside and out. No immediate health or safety concerns were observed.

Items that could constitute a danger to the residents are not properly stored

Regarding the allegation above, it was alleged sharp objects in the kitchen and chemical cleaners in bathrooms and laundry room were unlocked and accessible to residents. During the 8:55 a.m. physical plant tour, LPA observed Staff #1 (S1) using a knife to prepare food. Though the drawer was unlocked while S1 used the knife, S1 ensured the sharps were inaccessible to residents. S1 locked the drawer after storing the knife. LPA also observed no chemical cleaners in bathrooms. All chemical cleaners were locked and made inaccessible in the laundry room and chemical storage area.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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 4

Control Number 31-AS-20230313085609

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: WOODLAND WEST HOMES III	FACILITY NUMBER: 197606220
	VISIT DATE: 03/22/2023

NARRATIVE

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LPA interviewed Staff #2 (S2) at 9:10 a.m. and S1 at 9:20 a.m. Both S1 and S2 stated the key to open the locked cabinets is stored at a central location. S2 showed LPA the key at approximately 9:15 a.m. Based on observations and interviews, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Resident's door was not kept free of obstructions

Regarding the allegation above, it was alleged a dresser blocked the exit path in Bedroom #5. During the 8:55 a.m. physical plant tour, LPA observed a sliding glass door in Bedroom #5 which was unlocked. The dresser which allegedly blocked the exit door in Bedroom #5 was off to the side and not obstructing an exit path. 4 out of 4 bedroom exit doors were unlocked and unobstructed. 4 out of 4 auditory alarms were on and functioning. From interviewing S2 at 9:10 a.m. it was discovered that the resident who occupied Bedroom #5 had no issues with accessing the outdoor area via the exit door. Based on observations and interviews, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20230313085609

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: WOODLAND WEST HOMES III	FACILITY NUMBER: 197606220
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/31/2023 Section Cited CCR 87470(c)(1)(F)	1 2 3 4 5 6 7	87470 Infection Control Requirements (c) An Infection Control Plan shall be developed... (1) The Infection Control Plan shall include... (F) Staff shall demonstrate knowledge of and skill in infection control This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee ensured all staff wore masks during visit. Licensee will provide a written statement to ensure all staff follow the Infection Control Plan by POC due date.
	8 9 10 11 12 13 14	Based on observations and interviews, the licensee did not comply with the section cited above in 1 out of 2 staff which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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