197609049-11-29-2023-31-AS-NMAN-CY8VGR-20231205152555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 11/29/2023
Date Signed: 11/29/2023 04:58:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/18/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230918143720

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	CHA, TAMMIE		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 43	DATE:	11/29/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Stephanie Oden		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Terms of admission agreement were not followed

INVESTIGATION FINDINGS:

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At 8:45 a.m. on 11/29/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility at 11:30 a.m. today.

Regarding the allegation “Terms of admission agreement were not followed” it was alleged a rent increase was imposed that violated the terms of resident admission agreements. To investigate the allegation, LPA conducted an initial complaint visit at 11:30 a.m. on 09/20/2023 and interviewed the administrator at 11:45 a.m. and four (04) residents between 12:00 p.m. and 2:30 p.m., and reviewed records between 11:50 a.m. and 2:15 p.m. including but not limited to the staff list, resident list, and rent increase letters sent from the facility to residents. LPA also toured the physical plant at approximately 1:00 p.m. During a subsequent visit at 9:10 a.m. on 10/03/2023, LPA interviewed four (04) staff members between 9:15 a.m. and 12:00 p.m. and one (01) resident at 10:00 a.m. and reviewed records at 11:30 a.m. including but not limited to a resident list, staff list, and admission agreements.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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 5

Control Number 31-AS-20230918143720

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609049
	VISIT DATE: 11/29/2023

NARRATIVE

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On another subsequent visit on 10/09/2023, LPA interviewed four (04) staff and 10%, or five (05) out of forty-five (45) residents between 11:15 a.m. and 2:00 p.m. Interviews with residents revealed rent increase letters were sent on or around 09/14/2023. Record review of five (05) rent increase letters and five (05) admission agreements at 2:15 p.m. on 09/20/2023 revealed one of the letters violated the terms specified in the admission agreement of Resident #1 (R1). R1’s admission agreement noted “Pursuant to agreements made with Lilit Chaparyan, Executive Director, on behalf of Fallbrook Glen, there will be no additional fees, increases, or charges to Resident for rent, medication services, nursing, ancillary services, or any other services referenced in this agreement for the duration of their residency” Based on interviews and record review, the facility did not follow the terms of R1’s admission agreement when issuing rental increase notices. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on the attached LIC 809-D page.

No immediate health or safety hazards were observed during this visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20230918143720

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/08/2023 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee rescinded rent increase notices on 10/03/2023. Deficiency cleared.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above in one (01) out of five (05) admission agreements, which poses a potential Health, Safety, or 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/18/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230918143720

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	CHA, TAMMIE		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 43	DATE:	11/29/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Stephanie Oden		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Residents received Improper eviction notices

INVESTIGATION FINDINGS:

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At 8:45 a.m. on 11/29/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility at 11:30 a.m. today.

Regarding the allegation “Residents received Improper eviction notices” it was alleged the licensee sent eviciton notices with rental increases. To investigate the allegation, LPA conducted an initial complaint visit at 11:30 a.m. on 09/20/2023 and interviewed the administrator at 11:45 a.m. and four (04) residents between 12:00 p.m. and 2:30 p.m., and reviewed records between 11:50 a.m. and 2:15 p.m. including but not limited to the staff list, resident list, and rent increase letters sent from the facility to residents. LPA also toured the physical plant at approximately 1:00 p.m. During a subsequent visit on 10/09/2023, LPA interviewed 10%, or five (05) out of forty-five (45) residents between 11:15 a.m. and 2:00 p.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20230918143720

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609049
	VISIT DATE: 11/29/2023

NARRATIVE

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Interviews revealed nine (09) out of nine (09) residents did not receive eviction notices. Interview with the administrator at 11:45 a.m. on 09/20/2023 revealed the facility did not send eviction notices. Record review at 2:15 p.m. on 09/20/2023 revealed five (05) out of five (05) rental increase notices reviewed did not mention evictions. Based on interviews and record review, the facility did not issue improper eviction notices. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health or safety hazards were observed during this visit.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5