197609049-10-21-2022-31-AS-RRAZ-CWP5LS-20231016200338

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:19:31 AM

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
05/13/2021 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20210513153635

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: 91	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Elizabeth Whittington		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff mismanaged resident's medication.
Facility staff drinking alcohol on the premises during working hours.

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Michael Cava. Upon arrival, the LPA met with the administrator, Elizabeth Whittington.

Regarding the allegation above it was reported that on 5/5/2021, two (2) staff, who were scheduled to work the 11:00 pm to 6:00 am shift, were drinking during their working hours. It is also alleged that both staff failed to provide proper care and supervision as well as medication assistance to residents in care. It was reported that staff 1 (S1) left the facility prior to the end of his shift, while staff 2 (S2) was found asleep in the theater room.

An initial 10-day complaint visit was conducted by LPA Avetisyan on 5/20/2021. At which time interviews were held with administrator Lilit Chaparyan, med-tech and facility nurse. On various days in the month on

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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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Control Number 31-AS-20210513153635

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: 10/21/2022

NARRATIVE

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02/2022, LPA Avetisyan corresponded with the administrator via email and requested additional documents/information to be submitted related to the allegations listed above.

A Subsequent complaint visit was conducted by LPA Avetisyan on 7/20/2022. During the visit from approximately 5:45 am to 8:00 am, LPA Avetisyan conducted interviews with various staff from assisted living and memory care who were working the 10:00 pm to 6:00 am shift and staff working the 6:00 am to 2:00 pm shift. Approximately 8:15 am LPA conducted review of 5 staff and 1 resident file.

On 7/26/2022 LPA Avetisyan received a copy of the licensee's Internal investigation report.

Information obtained during the investigation confirmed that S1 and S2 both consumed alcohol during their shift. Various staff became aware of the incident through communication with both staff, through word of mouth from other staff, and through S2's social media account. As a result of the alcohol consumption, several residents have reported not to receive assistance with their care needs including but not limited to incontinence care and medication assistance.

Based on the information obtained, there was sufficient evidence to support both allegations. Therefore, the investigation is Substantiated. Citation(s) issued on the 9099D

Exit interview conducted, copy of report citations and appeal rights issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210513153635

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: 10/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/21/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met as evidenced by confirmation that S1 & S2 were drinking alcohol on the premises during working	1 2 3 4 5 6 7	As POC, the licensee will conduct staff training to address this section of the regulations. As proof training was held, the licensee will submit training log with date and attendance to CCL no later than 11/03/2022.
	8 9 10 11 12 13 14	working hours. As a result, several residents reported to not receiving assistance with their care needs and medication assistance, which poses an immediate health and safety and personal rights risk to persons 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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