197609049-6-10-2023-31-AS-NMAN-CUKMSF-20230810095153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 06/10/2023
Date Signed: 06/10/2023 05:19:01 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 HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	DANA ANDERSON		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 63	DATE:	06/10/2023
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Chad Boeddeker		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care.
Staff did not administer medications as ordered by physician.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with the Activities Direcror, Pat Acosta, and explained the reason for the visit. The Executive Director, Chad Boeddeker, disgnated Pat Acosta as the responsible person to sign and accept this report.

---Resident sustained multiple falls while in care.

It was alleged that Resident #1 (R1) had multiple falls while in care. To investigate the allegation, on 05/11/2023, LPAs Duguma and Tan requested documents at 10:00 AM. The facility's Narraive Charting revealed that R1 had multiple falls while in care. Hospital records, physician's report and the needs and service plan all stated that R1 was a fall risk, however, the needs and service plans were not updated accordingly to mitigate falls after hospitalization.

(CONT. on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

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-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: 06/10/2023

NARRATIVE

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Based on record review, 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):

---Staff did not administer medications as ordered by physician.

It was alleged that R1's eye drop medication was not administered and refilled as prescribed by physician. To investigate the allegation, on 05/11/2023, LPAs Duguma and Tan requested documents at 10:00 AM and interviewed six (06) staff at 11:00 AM. Hospital records indicate that medication was last refilled 06/03/2021. Facility was unable to provide documentation showing that medication was refilled around April or May 2021 which would have been the approximate refill date for medication refilled 02/12/2021. During interviews with staff, Staff #2 stated R1 was given medication as prescribed and R1 did not protest or refuse. The remaining five (05) out of six (06) staff stated they do not have any information about R1 as it relates to medication administration and refills.

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):

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC9099 (FAS) - (06/04)

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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: 06/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/12/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident.. The licensee shall ensure...observed for changes in physical, mental, ...functioning .... appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	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 87466 Observation of the Resident; The written letter must be sent to the LPA by the POC due date.
	8 9 10 11 12 13 14	Based on record review, the facility did not take any action to mitigate the falls for R1. R1 had multiple falls which posed an immediate health, safety and personal rights risk to resident in care.	8 9 10 11 12 13 14
Type A 06/12/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	(a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following:(4)The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	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 87465 Incidental Medical and Dental Care; The written letter must be sent to the LPA by the POC due date.
	8 9 10 11 12 13 14	Based on document review and interviews the Licensee did not ensure R1 was administered medication as prescribed. This poses an immediate health and safety or personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC9099 (FAS) - (06/04)

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