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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609049
Report Date: 09/04/2020
Date Signed: 09/04/2020 04:28:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 55DATE:
09/04/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dana Anderson TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Case Management Incident visit to the facility regarding the Special Incident Report (SIR) that was submitted to the department on September 4, 2020.

On 08/26/2020 family of resident 1 (R1) reported that resident 2 (R2) entered R1's room pushed, laid down next to R1 and proceeded to touch R1 inappropriately/sexually. Per administrator an SOC 341 was completed and forwarded to the Department, Long Term Care Ombudsman and mailed to the Police Department.

During this visit LPA conducted interview with the administrator Dana Anderson and other relevant individuals.

Ms. Anderson was informed that further investigation is needed regarding the incident

Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Administrator. Signatures will be obtained via email.



SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020
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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