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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:34:51 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
09/13/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220913121702
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: 94DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth GonzalesTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff did not answer call button timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.
LPA conducted a physical plant tour from 10:05-10:20am. No immediate health and safety issues were noted.

Regarding the allegation above it is alleged that resident #1 (R1) had a fall in their room and pulled the pull chord and it took staff more than twenty minutes to respond. LPA spoke with facility staff regarding this allegation and obtained documentation related to this allegation. Interview revealed that on the early morning of 9/13/22 R1 pulled the pull chord in the bathroom and waited for assistance. After receiving no response R1 made there way to their bed and pulled the pull chord and it took staff over twenty minutes to respond. LPA obtained pull chord record and observed that it took staff twenty seven minutes to respond to R1's room. Based on the information obtained through interview and documentation this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 4
Control Number 31-AS-20220913121702
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: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All facilities:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Facility shall have an in-service with staff regarding answering pull chords in a timely manner. Copy of in-service sign in sheet shall be submitted to LPA.
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Based on interviews and documentation it took staff over twenty five minutes to respond to R1's pull chord. This posed an immediate health and safety risk to residents in care.
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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: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
09/13/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220913121702

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: 94DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth GonzalesTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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The facility does not have a Qualified Administrator at this time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.
LPA conducted a physical plant tour from 10:05-10:20am. No immediate health and safety issues were noted.

It is alleged that the facility does not have a Qualified Administrator at this time. LPA conducted an interview with facility staff regarding this allegation. Interview revealed that the administrator quit working at the facility on 9/9/22 with no notice. The facility was not aware that the administrator was going to quit. LPA spoke with the previous administrator by telephone and verified that it was their decision to leave and no notice was provided to the facility. Interviews with facility staff revealed that the facility is hiring a new administrator they hope to have in place by the beginning of October 2022. For the time being facility has someone from corporate coming to the facility two-three times a week. LPA informed staff for them to send in an updated LIC 308 Designation of Facility Responsibility. Based on the information obtained this allegation is deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 4