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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:19:11 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
07/02/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20210702144233
FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 63DATE:
05/11/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chad BoeddekerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not respond to requests for assistance.
Resident did not receive modified diet as ordered by physician.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Abeye Duguma and Gary Tan conducted an unannounced subsequent complaint visit to the facility. LPAs met with the Executive Director (ED), Chad Boeddeker, and explained the reason for the visit.

---Staff did not respond to requests for assistance.

It was alleged that Resident #1 (R1) and Resident #2 (R2) waited for an extended time after requesting assistance via call button. To investigate the allegation on 05/11/2023, LPAs Duguma and Tan conducted a physical plant tour at 9:30 AM, requested additional documents at 10:00 AM and interviewed six (06) staff and six (06) residents from 11:00 AM – 1:30PM.

(CONT. LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
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 6
Control Number 31-AS-20210702144233
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: 05/11/2023
NARRATIVE
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During the physical plant tour LPAs tested the emergency call button and observed a response time between two (02) minutes to eight (08) minutes, however, The Individual Account Report shows that there are multiple incidents where the response time for resident call pendants ranges from 20.22 minutes to 1hr and 47.35 minutes. During interviews with residents, three (03) out six (06) residents stated that they do not use the emergency call button and the remaining three (03) residents stated that the response time ranges between fifteen (15) to thirty (30) minutes.

Based on record review and interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

---Resident did not receive modified diet as ordered by physician.

It was alleged that staff were not following dietary restrictions. To investigate the allegation on 07/08/2021, LPA Angelica Arambulo requested pertinent documents. On 05/11/2023, LPAs Duguma and Tan requested additional documents at 10:00 AM and interviewed six (06) staff. A review of R1’s Physicians Report shows that R1 has a special diet ordered by a physician. During interviews with staff, Staff #3 (S3) stated they do not have a dietary list and all residents are served the same food. Staff #4 (S4) stated that residents are being served food according to their dietary restrictions. When LPAs asked S4 to produce the list, S4 was unable to satisfy the request.

Based on record review and interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview was conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
07/02/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20210702144233

FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 63DATE:
05/11/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chad BoeddekerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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2
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9
 Resident did not receive showers per their care plan.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Abeye Duguma and Gary Tan conducted an unannounced subsequent complaint visit to the facility. LPAs met with the Executive Director (ED), Chad Boeddeker, and explained the reason for the visit.

---Resident did not receive showers per their care plan.

It was alleged that staff were not following showering schedule for R1. To investigate the allegation on 07/08/2021, LPA Angelica Arambulo requested pertinent documents and on 05/11/2023, LPAs Duguma and Tan interviewed six (06) staff and six (06) residents from 11:00 AM – 1:30 PM. A review of R1’s care plan revealed that R1 needs assistance with showering and that R1 was scheduled for three (03) showers per week.

(CONT. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
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 6
Control Number 31-AS-20210702144233
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: 05/11/2023
NARRATIVE
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During interviews with staff, Staff #5 (S5) and Staff #6 (S6) stated that they follow each resident’s shower schedule and the only time that they deviate from the schedule is when the resident protests and refuses in which case they give residents a sponge bath. During interviews with residents, all residents stated that, if needed, they receive showering assistance and staff follow their schedules accordingly.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20210702144233
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: 05/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/18/2023
Section Cited
CCR
87555(b)(7)
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General Food Service Requirements:(b) The following food service requirements shall apply: (7)Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by;
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The Executive Director will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87303 General Food Service Requirements. The written letter must be sent to the LPA by the POC due date.
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Based on interviews, Staff #3 and Staff #4 were unable to produce documentation showing residents dietary restrictions. This poses a potential health safety and personal rights risk to residents in care.
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Type B
05/18/2023
Section Cited
CCR
87411(a)
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Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance
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The Executive Director will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87411(a) Personnel Requirements. The written letter must be sent to the LPA by the POC due date.
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of buildings, equipment and grounds...The requirement is not met as evidenced: Based on record review and interviews, it could take staff 10 mins to over an hour to respond and/or assess a call button request. This poses a potential health safety and personal rights 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6