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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 02/08/2023
Date Signed: 02/08/2023 01:36:16 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
01/30/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230130094323
FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:LILIT CHAPARYANFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 75DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility kitchen area is not kept free of insects
INVESTIGATION FINDINGS:
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At 10:15 a.m. on 02/08/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Administrator and disclosed the reason for the visit.

LPA interviewed the Administrator at 10:22 a.m., conducted a records review at 11:08 a.m., and toured the facility at 11:32 a.m. Regarding the allegation above, it was alleged the facility kitchen contained cockroaches.
From facility tour, LPA observed a live cockraoch in the kitchen at 11:55 a.m. From interviews, the Administrator stated the kitchen was scheduled for fumigation last week, but the appointment had to be rescheduled for this week. From record review, a pest control company was scheduled for four services for the month of February 2023. Based on observations, interviews, and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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 3
Control Number 31-AS-20230130094323
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: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2023
Section Cited
CCR
87555(b)(27)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement was not met as evidenced by:
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Licensee will schedule fumigation of the kitchen within 7 days and ensure no insects are present in the kitchen by the POC due date.
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Based on observations, record review, and interview, the licensee did not comply with the section cited above which poses an immediate Health, Safety, or 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3