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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609049
Report Date: 09/13/2023
Date Signed: 09/13/2023 04:33:23 PM


Document Has Been Signed on 09/13/2023 04:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:CHA, TAMMIEFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 52DATE:
09/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Stephanie OdenTIME COMPLETED:
04:30 PM
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At 4:00 p.m. on 09/13/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the Administrator and disclosed the reason for the visit.

Today’s case management visit was conducted in response to the facility reporting Staff #1 (S1) made an unwanted sexual advance towards Resident #1 (R1).

LPA attempted to interview R1 today at 4:10 p.m. and reviewed records at 4:20 p.m. LPA will return at a later date to complete interview with R1 and conduct additional interviews.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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