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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609049
Report Date: 11/30/2022
Date Signed: 11/30/2022 12:48:56 PM


Document Has Been Signed on 11/30/2022 12:48 PM - It Cannot Be Edited

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:LILIT CHAPARYANFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 87DATE:
11/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
12:58 PM
NARRATIVE
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At 9:45 a.m. on 11/30/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the Administrator and disclosed the reason for the visit. On 11/29/2022 the Woodland Hills-South Regional Office received an incident report from the facility regarding the inappropriate touching of Resident #1 (R1) by Resident #2 (R2). LPA interviewed the Administrator at 10:10 a.m. and conducted a record review at 10:30 a.m. LPA reviewed resident files and staff schedule.

From interviews, the Administrator noted R2’s confusion during recent conversations. R2 admitted to having some memory problems but did recall inappropriately touching R1. R2 did not see anything wrong with the touching. From record review, R2 had no history of inappropriate behaviors. R2’s physician’s report showed a primary diagnosis of dementia. Based on record review and interviews, the facility did not implement safety measures to address the inappropriate behavior of R1. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, a deficiency was cited on the attached LIC 9099-D page.

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

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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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Document Has Been Signed on 11/30/2022 12:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited

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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address aggressive behavior.
This requirement was not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above in 1 resident which poses a potential Health, Safety, or Personal Rights risk.
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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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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