197609049-10-12-2023-31-AS-NMAN-CZEPSU-20240112103455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:31:11 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
02/03/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230203161359

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	LILIT CHAPARYAN		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 45	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Stephanie Oden		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff are not maintaining resident's room clean, sanitary and free of odors.

INVESTIGATION FINDINGS:

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At 12:40 p.m. on 10/12/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the current administrator and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial complaint visit on 02/08/2023 and interviewed the former administrator at 10:20 a.m. LPA conducted a subsequent visit on 09/13/2023 and interviewed residents and staff between 11:00 a.m. and 1:00 p.m. LPA conducted another subsequent visit on 09/20/2023 and interviewed additional residents and staff between 11:15 a.m. and 2:00 p.m. LPA interviewed visitors at 3:00 p.m. on 02/28/2023, at 3:30 p.m. on 10/11/2023, and at 1:00 p.m. today.

Regarding the allegation “Facility staff are not maintaining resident's room clean, sanitary and free of odors” it was alleged Resident 1's (R1) room contained strong odors of urine.

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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

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
02/03/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230203161359

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	LILIT CHAPARYAN		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 45	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Stephanie Oden		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff are not ensuring that resident has clean bedding/blankets.

INVESTIGATION FINDINGS:

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At 12:40 p.m. on 10/12/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the current administrator and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial complaint visit on 02/08/2023 and interviewed the former administrator at 10:20 a.m. LPA conducted a subsequent visit on 09/13/2023 and interviewed residents and staff between 11:00 a.m. and 1:00 p.m. LPA interviewed visitors at 3:00 p.m. on 02/28/2023, at 3:30 p.m. on 10/11/2023 , and at 1:00 p.m. today.

Regarding the allegation “Facility staff are not ensuring that resident has clean bedding/blankets” it was alleged the facility did not provide sufficient fresh linens to Resident #1 (R1).

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20230203161359

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: 10/12/2023

NARRATIVE

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Interview with Visitor #1 (V1) at 3:30 p.m. on 10/11/2023 and with Visitor #2 (V2) at 1:00 p.m. today revealed that R1 habitually placed their clean, fresh beddings in the laundry. Interview with Visitor #3 (V3) at 3:00 p.m on 02/28/2023 revealed that R1 filled two large bags with laundry within 24 hours. Interview with Staff #1 (S1) at 11:10 a.m. on 09/13/2023 revealed housekeeping provided laundry services to most residents once per week. Interview with Staff #2 (S2) at 12:45 p.m. on 09/13/2023 revealed housekeeping provided laundry service to R1 twice per week as the facility knew about R1’s increased laundry needs. Interview with R1 at 12:30 p.m. on 09/13/2023 revealed no pertinent information. Based on interviews, there is insufficient evidence to validate the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20230203161359

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: 10/12/2023

NARRATIVE

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Interview with Visitor #3 (V3) at 3:00 p.m. on 02/28/2023 revealed R1 was constantly urinating on their furniture and carpet, and the odor was so strong that V3 had difficulty being inside of the room. Interviews with the former administrator at 10:20 a.m. on 02/08/2023 and Staff #3 (S3) at 1:00 p.m. on 09/20/2023 revealed the facility was aware of R1’s incontinence issues. Interview with Staff #1 (S1) at 11:10 a.m. on 09/13/2023 confirmed that housekeeping performed a deep cleaning of rooms once a week which entailed vacuuming and cleaning. S1 admitted R1’s room was constantly odorous even after cleanings. Interview with R1 at 12:30 p.m. on 09/13/2023 revealed no pertinent information. Based on interviews, there is sufficient evidence to validate the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this time.

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20230203161359

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: 10/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/23/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct an in-service training on room maintenance and cleanliness and implement additional carpet and furniture cleaning when odors are noted. Proof of correction for training due by POC due date.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above in 1 out of 1 resident rooms which poses a potential Health, Safety, or Personal Rights risk to residents 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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5