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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:26:02 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
08/23/2021 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20210823145706
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: 91DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Licensee/staff failed to meet Resident 1 (R1's) needs
Resident 1 (R1) did not have any sheets/pillowcases on bed
Resident 1 (R1's) room was left unsanitary.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Michael Cava to deliver the findings regarding the above allegations. Upon arrival, the LPA met with the administrator, Elizabeth Whittington.

Regarding the allegations listed above it was reported that licensee/staff failed to meet Resident 1 (R1's) need by failing to provide showers as documented in the 7/23/2021 AL Advantage Resident Assessment, failed to provide proper incontinence care, and failed to reposition R1 every 2 hours. It was also reported R1 did not have sheets/pillowcases placed on her bed and a bucket of urine was left in R1's room.

On 9/1/2021 an initial 10-day complaint visit was conducted by LPA Y. Avetisyan. During the visit LPA conducted telephone interview with Administrator Lilit Chaparyan and reviewed R1’s facility file. LPA also obtain copies of documents pertinent to the investigation. Additionally, on various days from
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (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)
Page: 1 of 6
Control Number 31-AS-20210823145706
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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10/2021 to 3/2022 LPA Avetisyan communicated with the administrator and facility LVN via email regarding the allegations listed on this complaint. On 9/2/2021 LPA was forwarded copy of email communication between the administrator and R1's family/responsible party.

Based on the documentation received, dated 7/23/21, there was sufficient evidence that the licensee failed to provide R1 with showers. The licensee also failed to provide proper incontinent care and to reposition R1 every two hours as indicated on their AL Advantage Resident Assessment, Preplacement Appraisal, Resident Appraisal, and Physician Report. Furthermore, there was also enough evidence to conclude that resident lacked sheets and pillowcases and a bucket of urine being left in R1’s room. Therefore, the above allegations are Substantiated. Citation(s) issued on the 9099D. Exit interview conducted, copy of report, citations and appeal rights issued.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (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)
Page: 2 of 6
Control Number 31-AS-20210823145706
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 B
10/21/2022
Section Cited
CCR
87464(d)
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Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission
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continued from Deficiencies: rights risk to persons in care.

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
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Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement has not been met as evidenced by documents obtained by LPA Avetisyan between 10/2021 and 3/2022, which poses a potential health and safety and personal
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date and attendance to CCL no later than 11/03/2022
Type B
10/21/2022
Section Cited
CCR
87307(3)(c)
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Personal Accommodations and Services: Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the
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Continued from Deficiencies: Avetisyan between 10/2021 and 3/2022, which poses a potential health and safety and personal rights risk to persons in care

As POC, the licensee will conduct staff training to address this section of the
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licensee shall assure provision of: Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. This requirement has not been met as evidenced by documentation obtained & reviewed by LPA
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regulations. As proof training was held, the licensee will submit training log with date and attendance to CCL no later than 11/03/2022
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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (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)
Page: 3 of 6
Control Number 31-AS-20210823145706
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 B
10/21/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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POC: 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
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This requirement has not been met as evidenced by documentation obtained & reviewed by LPA Avetisyan between 10/2021 and 3/2022, which poses a potential health and safety and personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (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)
Page: 4 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
08/23/2021 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20210823145706

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: 91DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident 1 (R1) did not receive proper medical care upon admission to the facility:
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with the administrator, Elizabeth Whittington.

Regarding the allegation listed above, it is being alleged that upon admission to the facility Resident 1 (R1) did not receive medical care for their Restricted Health Condition (Stage 2 Pressure injury). This investigation was conducted by Laura Garcia, Investigator with Community Care Licensing Division’s Investigations Branch (IB).

On 9/1/2021 an initial 10 day complaint visit was conducted by LPA Y. Avetistyan. During the visit LPA conducted telephone interview with Administrator Lilit Chaparyan and reviewed R1’s facility file. LPA also obtain copies of documents pertinent to the investigation. Additionally on various days from 10/2021 to 3/2022 LPA communicated with the administrator and facility LVN via email regarding the allegations listed on this complaint.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (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)
Page: 5 of 6
Control Number 31-AS-20210823145706
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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On 11/15/2021 Investigator Garcia conducted review of hospital records from Kaiser. The Kaiser records reviewed were for dates prior to R1 being admitted to the facility. On 01/18/2022 and 2/25/2022 Investigator Garcia conducted review of records from Silverado Hospice and CVH Home Health. Additionally, on various days from 09/08/2021 to 02/26/2022 Investigator Garcia conducted interviews with facility residents, administrator, staff, and other relevant parties.

The review of the records revealed the following: R1 was admitted to the facility 7/29/2021 with a stage 2 pressure injury. R1 was receiving care for the pressure injury from CVH Care. According to CVH Care records and interviews on 7/31/2021 the pressure injury was diagnosed as Unstageable. CVH care continued to provide wound care until R1 was hospitalized on 8/4/2021. On 8/8/2021 R1 was returned to the facility with hospice care.

Facility records reviewed and Interviews conducted with facility staff by Investigator Garcia and LPA Avetisyan revealed the following: Administrator and facility LVN were not aware of R1’s pressure injury upon admission. On 8/4/2021 the pressure injury was observed and documented on the licensees end of shift log.

Information obtained during the course of the investigation revealed that R1 was admitted to the facility with a stage 2 pressure injury, although administrator and staff were not aware of the pressure injury, medical care was being provided for the pressure injury by CVHCare Home Health therefore the allegation is Unsubstantiated at this time.


Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (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)
Page: 6 of 6