197609049-8-24-2022-31-AS-CHAS-CJ9TBM-20220914143516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 08/24/2022
Date Signed: 08/24/2022 01:39:09 PM

Unsubstantiated

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
08/22/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220822095607

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	LILIT CHAPARYAN		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 91	DATE:	08/24/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Lilit Chaparyan		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to provide a safe environment for resident in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit.
LPA conducted a physical plant tour from 10:10-10:20am to ensure no immediate health and safety issues were present and none were noted.

Regarding the allegation it is alleged that staff have failed to provide a safe environment due to resident #1 (R1) not feeling safe due to R2's dog barking throughout the day and on two different occasions R1 has felt that they were going to be attacked by the dog due to the dog being off it's leash and the dog interuppting a therapy session for R1. LPA conducted an interview with the administrator regarding this allegation from 10:20-11am. LPA also conducted an interview with R1 regarding this allegation from 11-11:30am. LPA also interviewed R2 from 11:45-12pm regarding their dog. Information from interviews revealed that there has been some issues with R2's dog barking and being off of their leash. Administrator has been in contact with R2's family regarding the dog, and different measures have been tried to get the dog to stop barking as much and to keep the dog on their leash.

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: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

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-20220822095607

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: FALLBROOK GLEN OF WEST HILLS	FACILITY NUMBER: 197609049
	VISIT DATE: 08/24/2022

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

LPA received copies of documentation that the facility has been communicating with residents and R2's family regarding the dog. Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time. No residents have been bitten or had injury caused by R2's dog and the facility has been working to come up with a solution that will work for all residents. Exit Interview conducted. Copy of report issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2