197609049-10-24-2022-31-AS-CHAS-CLLVFJ-20221128152359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 10/24/2022
Date Signed: 10/24/2022 02:37:43 PM

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
08/12/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220812121935

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:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Elizabeth Whittington		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident is not provided clean linen.
Resident's room is dirty.
Resident is not provided clothing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit.
Regarding the allegations above it is alleged that resident #1 (R1) when they were in the facility did not have clean linen provided to them, that there room was not cleaned, and that they were not provided clean clothing for a period of time. LPA conducted visits on 8/15/22 and 9/16/22. During those visits interviews were conducted with facility staff. Information obtained during those interviews revealed that R1 was in the facility for over a month and was in the memory care unit. During the time that R1 was there, there was a covid outbreak in the memory care unit and the facility was short staff during that time. So basic services such as washing and cleaning rooms did not get done as they were supposed to based on staff shortage and the most of the residents in memory care came down with covid. Based on the information obtained through interviews all three allegations are deemed Substantiated. Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.

Substantiated

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: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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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Control Number 31-AS-20220812121935

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/24/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All facilities-Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Corrected before visit. Facility had staff training on 10/20/22. Copies of training given to LPA.
	8 9 10 11 12 13 14	Based on interviews conducted R1's room wasn't cleaned, bed linen was not changed, and clothes weren't changed as they should have been which posed a potential personal rights risk to residents 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: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
08/12/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220812121935

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:	DATE:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Elizabeth Whittington		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not inform authorized representative of resident's change of medical condition.
Staff did not safeguard resident's personal items.

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit. LPA conducted visits on 8/15/22 and 9/16/22 to interview staff and obtain copies of pertinent information.

Staff did not inform authorized representative of resident's change of medical condition.
It is alleged that resident #1 (R1) had a fall in the facility and failed to notify R1's family of the correct hospital R1 was taken to. LPA conducted interviews with facility staff and R1's family regarding the allegation. Information from interviews did not reveal enough information to state that R1's family wasn't informed of the hospital R1 was taken to. Interviews did show that R1's family was notified of R1's fall that happened in the facility on the same day. Based on the information obtained this allegation is deemed Unsubstantiated at this time.

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: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20220812121935

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: 10/24/2022

NARRATIVE

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Staff did not safeguard resident's personal items.
It is alleged that several of R1's belongings were missing when R1 was moved out of the facility. LPA conducted interviews with facility staff and R1's family. LPA checked R1's facility file and did not observe a property list for R1. Based on the information obtained through interviews and record review there is not enough information to state that the facility did not safeguard R1's personal items therefore this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

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