197609049-4-14-2021-31-AS-JAPL-C28TT7-20210419150014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 04/14/2021
Date Signed: 04/14/2021 02:50:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200514133637

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	VLADIMIR KAPLUN		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 71	DATE:	04/14/2021
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Lilit Chaparian		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not keep the facility free from insects.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ashley Smith and Aja Richardson arrived unannounced at 9:05am for a subsequent complaint investigation to issue the findings for the above allegations. The LPAs met with Executive Director Lilit Chaparian and explained the reason for the visit.

During the 5/19/2020 virtual visit, the LPA interviewed staff from 2:10-2:40pm and requested documents. In addition, the LPA conducted staff interviews on 5/20/2020 at 4:27pm and 5/22/2020 at 11:01am. During today’s visit, the LPAs interviewed four staff from 9:24am – 10:44am, and an additional staff interview at 1:17pm. A physical plant tour was conducted at 10am, and six resident interviews were conducted between 10:59am – 1:12pm.

CONT 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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 5

Control Number 31-AS-20200514133637

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: FALLBROOK GLEN OF WEST HILLS	FACILITY NUMBER: 197609049
	VISIT DATE: 04/14/2021

NARRATIVE

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Regarding the allegation: Staff did not keep the facility free from insects.

It was alleged that the facility was infested with roaches. The investigation revealed that this facility contracts with a pest control company which treats random rooms and common areas. This company also treats the perimeter of the facility for pests and bugs. The LPAs obtained documentation, noting that the pest control company treats the facility once a month. Interviews revealed that in general, the residents did not feel that there was a serious problem with pests. However, the Maintenance Log confirmed that residents have submitted complaints regarding bugs within the past week. In addition, interviews revealed that individuals had observed roaches in the common hallways within the past week.

Based on the investigation, there is sufficient evidence to support the claim that the staff did not keep the facility free from insects. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. The report was signed, however a copy of the signed report was emailed, along with the appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200514133637

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	VLADIMIR KAPLUN		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 71	DATE:	04/14/2021
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Lilit Chaparian		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not keep the facility clean.
The facility is in disrepair.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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-20200514133637

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: FALLBROOK GLEN OF WEST HILLS	FACILITY NUMBER: 197609049
	VISIT DATE: 04/14/2021

NARRATIVE

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Regarding the allegation: Staff did not keep the facility clean.

It was alleged that the cleaning staff did not properly clean and disinfect the facility, and that it would take weeks to properly remove trash from the floor. Resident interviews revealed that housekeeping staff are cleaning and disinfecting the rooms once a week, and care staff will come though and do light maintenance. Residents also confirmed that if possible, they will take out their own trash. During today’s visit, the LPAs observed the facility overall to be in good condition. The LPAs observed multiple housekeeping staff servicing rooms and common areas throughout the visit.

Based on the investigation, there is insufficient evidence to support the claim that the staff did not keep the facility clean. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: The facility is in disrepair

It was alleged that at the time of the complaint was filed, the ceiling was being repaired. Interviews confirmed that repairs to the ceiling had been completed, as the fire alarm system was being updated to code. During a staff interview conducted on 5/20/2020, the staff sent over photos to demonstrate that the repairs to the ceiling had been completed. During today’s visit, the LPAs reviewed the Maintenance Log at 9:52am and noted that in general, work orders were completed in a timely manner. During the physical plant tour, the facility was observed to be in good condition.

Based on the investigation, there is insufficient evidence to support the claim that the facility is in disrepair. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. Report was signed by the Executive Director, yet a signed copy of the report was emailed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20200514133637

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: FALLBROOK GLEN OF WEST HILLS	FACILITY NUMBER: 197609049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/14/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. POC cleared at this time. The community continues to treat the pest control issues with monthly servicing and Maintenance will continue to identify the core problem of the incoming pests.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above, as the facility has a persistent pest issue and the facility has monthly pest control company to treat this building, which poses a potential health and safety 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5