197609049-11-2-2022-31-AS-MVAO-CKUTY5-20221104150811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:23:59 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
11/01/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20221101141649

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: 94	DATE:	11/02/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lizette Paniagua		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff failed to refill resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith made an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.
It is alleged that the facility failed to refill resident #1 (R1) medication in a timely manner. LPA conducted interviews with facility staff, R1's fiduciary, and Kaiser hospital staff from 10:15-11:15am regarding this allegation. LPA also spoke with the pharmacy that was handling R1's medications from 12-12:25pm. LPA also reviewed R1's facility file from 11:15-11:30am to get more information. Information from interviews reveal that R1 came to this facility on 6/26/22 and shortly loss insurance coverage which led to R1 not having insurance for medication or to have a primary care physician. The facility was able to have their house pharmacy refill R1's medications for awhile but after not getting paid the house pharmacy stopped doing the refills on R1's medications. The facility then had to step in and pay out of their own pocket to have R1's medications refilled. R1's fiduciary also confirmed the facility was attempting to get R1's medication refilled before it ran out on 10/12/22. Based on the information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.

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: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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