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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:21:37 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200428144437
FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:VLADIMIR KAPLUNFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 80DATE:
06/23/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Lilit Chaparian TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility does not have sufficient staffing
Facility not maintained at a comfortable temperature
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint investigation for the above allegations and to issue findings. The LPAs met with Executive Director Lilit Chaparian and explained the reason for the visit.

During a 5/6/2020 visit, LPA Desaree Perera interviewed facility staff between 2:27pm - 3:15pm and obtained documents. During a 4/14/2021 visit, the LPA Smith interviewed four staff from 9:24am – 10:44am, and an additional staff at 1:17pm. A tour was conducted at 10am, and six residents were interviewed between 10:59am – 1:12pm. A hospice representative was interviewed on 5/8/2020 at 10:39am. During today’s visit, seven staff were interviewed between 10:19am – 2pm.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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 7
Control Number 31-AS-20200428144437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: FALLBROOK GLEN OF WEST HILLS
FACILITY NUMBER: 197609049
VISIT DATE: 06/23/2021
NARRATIVE
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Regarding the allegation: Facility does not have sufficient staffing
It was alleged that residents experience long wait-times when assistance is requested, and that the facility is especially understaffed during NOC shifts. The LPA reviewed call alert/pendant logs from 4/1/2020 – 5/7/2020 and on multiple occasions, residents waited over 20 minutes to receive assistance. Interviews confirmed that the facility experiences call outs and staffing issues, particularly during NOC shift, weekends, and holidays. Interviews revealed that whereas there are some residents that require a two-person assist, most staff will not move the resident without assistance of another staff person. Hence, staff confirmed that it may take 15-20 minutes to receive additional assistance to transfer a resident, which results in other residents waiting an extended period of time. Interviews with the Executive Director confirmed that the company was approved to hire an additional staff in the mornings to assist with care. Based on the investigation, there is sufficient evidence to support the claim of insufficient staffing. This allegation is deemed Substantiated at this time.

Regarding the allegation: Facility not maintained at a comfortable temperature
It was alleged that at the time of the submission of the complaint, the facility was warm and uncomfortable, and R1’s room temperature was not adjusted as necessary. Interviews and observations confirmed that each room has a personal air conditioner unit that the resident can adjust. Whereas independent and alert residents confirmed that they were able to adjust their unit as desired, residents whom were bedridden or required assistance from staff are limited in their capacity to adjust the air conditioning unit without assistance. Observations from a credible witness revealed that on more than one occasion, the temperature in R1’s room was uncomfortable and R1’s air conditioning unit was not on. As R1 was incapable of getting out of bed to adjust the unit, R1 required the assistance of staff to turn the unit on. Staff had to be reminded to turn on the air conditioning in R1’s room. Based on the investigation, there is sufficient evidence to support the claim that that the facility not maintained at a comfortable temperature, particularly in R1’s room. This allegation is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. Exit interview conducted. Appeal rights and a copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20200428144437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: FALLBROOK GLEN OF WEST HILLS
FACILITY NUMBER: 197609049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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The Administrator has agreed to the following: 1. Submit a comprehensive plan with how the facility will have sufficient staff to meet all the needs of residents in care in both Assisted Living and Memory Care by 6/25/2021.
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Based on interview and record review, the licensee did not comply with the section cited above, as the facility has experienced periods of insufficient staffing and extended wait periods in providing care, which poses an immediate health and safety risk to residents in care.
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Type B
06/25/2021
Section Cited
CCR
87303(b)
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87303(b) Maintenance and Operation. A comfortable temperature for residents shall be maintained at all times.
This requirement is not met as evidenced by:
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The Administrator has agreed to the following:
1. Submit a statement of understanding, documenting how the community will maintain a comfortable temperature for residents in the Memory Care unit whom are unable to operate their own air conditioning unit. Submit statement by 6/25/2021.
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Based on interview, the licensee failed to comply with the section cited above, as the air in a memory care unit was not maintained at a comfortable temperature, which poses a potential health and safety risk to residents 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200428144437

FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:VLADIMIR KAPLUNFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 80DATE:
06/23/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Lilit Chaparian TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care
Resident not provided assistance with incontinence care
Resident not hydrated on a regular basis
Resident fell at facility while in care
Resident not provided assistance with basic care needs
Resident left sitting for a prolonged period of time
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint investigation for the above allegations and to issue findings. The LPA met with Executive Director Lilit Chaparian and explained the reason for the visit.

During a 5/6/2020 visit, LPA Desaree Perera interviewed facility staff between 2:27pm - 3:15pm and obtained documents. During a 4/14/2021 visit, the LPA Smith interviewed four staff from 9:24am – 10:44am, and an additional staff at 1:17pm. A tour was conducted at 10am, and six residents were interviewed between 10:59am – 1:12pm. A hospice representative was interviewed on 5/8/2020 at 10:39am. During today’s visit, seven staff were interviewed between 10:19am – 2pm.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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 7
Control Number 31-AS-20200428144437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: FALLBROOK GLEN OF WEST HILLS
FACILITY NUMBER: 197609049
VISIT DATE: 06/23/2021
NARRATIVE
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Regarding the allegation: Resident sustained pressure injury while in care
It was alleged that R1 due to lack of repositioning, R1 sustained a pressure injury on their back. Records confirmed that on 4/22/2020, R1 was not observed with any pressure injuries. Medical records review confirmed that on 4/24/2020, a stage one pressure injury was observed on R1’s coccyx. Interviews with hospice representatives confirmed that the wound had minor redness and it had healed within a few days, which could be attributed to staff following the instructions in repositioning R1 and providing appropriate wound care. Interviews did not validate the claim that staff were negligent in repositioning R1 or inadequately providing incontinent care.

Records review also demonstrated that credible witnesses would either observe R1 in their bed or the wheelchair, which indicated that they were oftentimes moved for mobility reasons. Staff continued to place R1 in their wheelchair until they received instructions from hospice to limit R1's time out of bed. Credible witnesses did not communicate concern that staff were negligent in providing care for R1. Staff communicated that for bedridden residents, they were required to reposition residents at least every two hours. Based on the investigation, there is insufficient evidence to support the claim that due to neglect, R1 sustained a pressure injury. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident not provided assistance with incontinence care
It was alleged that because R1 sustained a pressure injury, it was possibly due to R1 not being changed for prolonged periods. Interviews with those whom provided care for R1 denied claims that they ever observed R1 to be wet for prolonged periods of time. In addition, it was communicated that R1 was never observed to be in soiled diapers and that it appeared that the facility was adequate in providing incontinence care. Interviews with staff confirmed that incontinent residents were checked and changed as often as needed, but at least every two hours. Based on the information obtained, there is insufficient evidence to support the claim that R1 was not provided assistance with incontinence care. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident not hydrated on a regular basis
It was alleged that as R1’s health began to decline, staff did not assist R1 with taking in liquids. Interviews with those whom provided care to R1 confirmed that R1 oftentimes did not have an appetite, and R1 had to be assisted with eating and drinking. Medical records confirmed that both facility and hospice staff would encourage R1 to eat and drink, yet R1 would communicate that they had little to no appetite.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 31-AS-20200428144437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: FALLBROOK GLEN OF WEST HILLS
FACILITY NUMBER: 197609049
VISIT DATE: 06/23/2021
NARRATIVE
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Staff confirmed that they ensured that R1 had water within reach, but also stated that they could not force R1 to drink. Hospice representatives and documentation confirmed that R1 had to be reminded to consume liquids yet communicated that R1 was oftentimes resistant. Interviews confirmed that beginning in April 2020, R1’s condition declined and R1 notably took in less food and liquids and had a decreased appetite. Lastly, there were no communicated concerns from collateral agencies that the facility was negligent in ensuring that R1 was hydrated. Based on the information obtained, there is insufficient evidence to support the claim that R1 was not hydrated on a regular basis. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident not provided assistance with basic care needs


It was alleged that the facility failed to meet R1’s basic care needs, such as changing R1 regularly, ensuring that R1 is consuming food and liquids, and ensuring that R1 is repositioned regularly. There was also a concern that R1 had lost weight due to staff neglecting to feed R1. Interviews and records review confirmed that R1 was never observed to be in soiled diapers and that it appeared that the facility was adequate in providing incontinence care. Interviews did not validate the claim that staff were negligent in repositioning R1. Interviews confirmed that R1 was not observed to be regularly soiled and it appeared that R1 was regularly changed. Records review also demonstrated that credible witnesses would either observe R1 in their bed or the wheelchair, which indicated that they were oftentimes moved for mobility reasons.

Interviews and records review confirmed that R1 had little to no appetite and as a result, had lost weight. Whereas it was alleged that R1 loss 30lbs between 3/12/2020 – 4/28/2020, there was no documentation to support the decline in weight, nor was there documentation to support the claim that the weight loss was due to facility neglecting to ensure that R1 was fed. R1’s poor appetite was documented prior to R1’s decline in health and records noted that R1’s decreased appetite was discussed with R1’s family and facility staff. Prior to R1’s decline, R1 was able to feed themselves with minimal assistance (as documented on R1’s assessment dated 2/27/2020), and records confirmed that R1 was observed and encouraged to eat. Interviews and records review confirmed that R1’s condition began to decline and per hospice notes, new orders required that R1 received assistance with feeding and hydrating as of 4/24/2020. This change of condition was also noted on R1’s assessment dated 4/28/2020. Records thereafter did not allege that the facility was negligent in providing for R1’s needs, particularly in feeding or ensuring that R1 was hydrated.

Based on the information obtained, there is insufficient evidence to support the claim that R1 was not provided assistance with basic care needs. This allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 31-AS-20200428144437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: FALLBROOK GLEN OF WEST HILLS
FACILITY NUMBER: 197609049
VISIT DATE: 06/23/2021
NARRATIVE
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Regarding the allegation: Resident fell at facility while in care
It was alleged that R1 was left in their wheelchair for an extended period of time and as a result, R1 attempted to move and fell. Hospice records as of 4/22/2020 indicated that R1 had not suffered any falls; however, notes instructed staff to monitor R1 for fall precautions when out of bed for meals. During a 4/24/2020 visit, it was indicated that R1 suffered a fall on 4/23/2020. Staff indicated that R1 slipped out of their wheelchair and that the fall was unwitnessed. At that point, hospice discontinued orders for R1 to be in their wheelchair for meals and noted that R1 would be up in their recliner for up to 30 minutes for meals with staff observation and assistance. R1 suffered another non-witnessed fall on 5/1/2020, in which R1 attempted to get out of bed to go to the restroom. At that point, R1 was reminded to use their pull cord, and additional fall prevention measures were ordered, and additional medication was ordered to assist with R1’s restlessness.

Based on the information obtained, there is insufficient evidence to support the claim that due to neglect, R1 fell at the facility. The facility followed all fall prevention measures once put in place and R1 was regularly reminded to use their call button. Whereas R1 is repositioned and checked every two hours, R1 could have fallen within that two-hour time period. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident left sitting for a prolonged period of time


It was alleged that the facility was neglectful in leaving R1 in their wheelchair for an extended period of time and as a result, R1 attempted to move out of the wheelchair and fell. Interviews with a family member for R1 stated that they believe R1 was sitting in the wheelchair for 3-4 hours prior to a fall on 4/23/2020, as they were speaking to R1 at various times during that time period and R1 indicated that they were ‘sitting by the window’. Soon after, R1’s family received a call, indicating that R1 had slid out of their wheelchair and fell. As a result, hospice ordered R1 to be in the wheelchair for no longer than 30 minutes and for R1 to be assisted with meals during that time to ensure that R1 was not left alone in recliner. However, interviews with collateral agencies confirmed that prior to the fall, the facility staff did their due diligence to have R1 out of bed and in the wheelchair, as it was good for mobility reasons and for R1’s health. In addition, R1 was checked on every two hours to assess for any change of condition. Whereas R1 suffered a non-witnessed fall, R1 could have fallen within that two-hour time period. Based on the information obtained, there is insufficient evidence to support the claim that the facility staff were neglectful in leaving R1 in the chair for a prolonged period of time. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7