197609049-11-4-2022-31-AS-CHAS-CLLVFH-20221128152358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:45:27 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
08/12/2022 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: 94	DATE:	11/04/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Elizabeth Whittington		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident fell in care causing injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to this facility to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit.
It is alleged that resident #1 (R1) sustained a fall and sustained a laceration above their eye due to facility negligence. LPA conducted previous visits on 8/15/22, 9/16/22, and 10/24/22. During those visits interviews were conducted with staff and R1’s family members. LPA also reviewed and obtained R1’s facility file which included R1’s plan of care, physician report, and resident assessment. Based on interviews and record review it was found that R1 was not a fall risk and was considered ambulatory. R1 did have a fall in the dining room and was attended to by staff. There was no evidence to suggest that R1 fell due to staff negligence. 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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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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