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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:29:00 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
09/25/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230925104214
FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:CHA, TAMMIEFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 36DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Andrea SaavedraTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not respond to resident's requests in a timely manner due to inadequate staffing
Staff does not provide residents with an itemized list of charges
INVESTIGATION FINDINGS:
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At 8:30 a.m. on 01/09/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the designee and disclosed the reason for the visit.

To investigate the allegations above, LPA conducted an initial visit at 9:10 a.m. on 10/03/2023 and interviewed the administrator at 9:35 a.m., Resident #1 (R1) at 10:00 a.m., Staff #1 (S1) at 11:15 a.m. and Staff #2 (S2) at 11:30 a.m., and reviewed records at 11:30 a.m. including but not limited to resident admission agreements and rent increase letters. LPA conducted a subsequent visit on 10/09/2023 and interviewed three (03) staff between 11:15 a.m. and 12:00 p.m. and five (05) out of forty-three (43) residents, or 10% of residents, between 12:00 p.m. and 1:15 p.m. LPA toured the facility today at 3:30 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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-20230925104214
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: 01/09/2024
NARRATIVE
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Regarding the allegation “Staff do not respond to resident's requests in a timely manner due to inadequate staffing” it was alleged multiple residents had to wait for staff assistance due to inadequate staffing. Interview R1 revealed they have had to wait days for assistance with showering and taking out trash. Resident #2 (R2) who was interviewed at 12:30 p.m. on 10/09/2023 stated they too have had to wait on shower assistance and even missed some shower days due to lack of staffing. R2 also had to wait 40 minutes one night for assistance. Resident #3 (R3) was interviewed at 1:05 p.m. on 10/09/2023 and stated staff try to help, but R3 felt their needs are not met by staff. Interview with the administrator revealed there was a staffing shortage, so the facility was in the process of hiring six (06) new employees. On most day shifts, there are two (02) caregivers to provide care and supervision to approximately 30 residents in assisted living and one (01) or two (02) caregivers for the memory care side. Staff #1 (S1) and Staff #2 (S2) were asked to detail their daily tasks as caregivers. S1 stated sometimes they are the only staff working in their unit especially when a staff member calls out or takes a break. S1 sometimes performs their duties while supervising and pushing a resident in a wheelchair who is a fall risk. Both S1 and S2 admitted there is not enough time in their shifts to adhere to the shower schedule and to complete their daily tasks. Based on interviews, the facility did not have sufficient staff to respond to resident requests. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 809-D page.

Regarding the allegation “Staff does not provide residents with an itemized list of charges” it was alleged that R2, as well as Resident #3 (R3) and Resident #4 (R4) were unwilling to pay the extra charges from the rental increase letters until they received an itemized list of charges. LPA interviewed R3 and R4 at 12:00 p.m. on 10/09/2023 as part of the investigation for complaint # 31-AS-20230918143720. It was determined from a record review at 11:50 a.m. on 09/20/2023 that the terms of R3’s admission agreement had not been followed by the rent increase letter. Since the facility rescinded the letter on 10/03/2023, R2, R3, and R4 were never charged extra. Based on interviews and record review, the facility did not provide residents with an itemized list of charges. The charges were never issued, so the allegation is deemed SUBSTANTIATED at this time with no deficiency.

No immediate health and safety hazards were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 31-AS-20230925104214
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: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) 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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Since the date of the allegation, the licensee has hired eight (08) additional staff.
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Based on interviews, the licensee did not comply with the section cited above which poses a potential Health, Safety, or Personal Rights 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
09/25/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230925104214

FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:CHA, TAMMIEFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 35DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is overcharging residents in care
Illegal eviction
INVESTIGATION FINDINGS:
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3
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5
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7
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13
At 8:30 a.m. on 01/09/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit.

To investigate the allegations above, LPA conducted an initial visit at 9:10 a.m. on 10/03/2023 and interviewed the administrator at 9:35 a.m., Resident #1 (R1) at 10:00 a.m., Staff #1 (S1) at 11:15 a.m. and Staff #2 (S2) at 11:30 a.m., and reviewed records at 11:30 a.m. including but not limited to resident admission agreements and rent increase letters. LPA conducted a subsequent visit on 10/09/2023 and interviewed three (03) staff between 11:15 a.m. and 12:00 p.m. and five (05) out of forty-three (43) residents, or 10% of residents, between 12:00 p.m. and 1:15 p.m. LPA toured the facility today at 3:30 p.m.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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-20230925104214
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: 01/09/2024
NARRATIVE
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***This page was amended on 01/10/2024 to correct typographical errors***

Regarding the allegation “Staff is overcharging residents in care.” it was alleged Resident #2 (R2) was charged extra for rent and care services. LPA interviewed R2 at 12:45 p.m. on 09/15/2023 as part of the investigation for complaint #31-AS-20230918143720. R2 noted that the extra charges for rent and care came from rent increase letters which all residents received on 09/14/2023. R2 clarified that they were not yet required to pay extra charges, but the additional charges were proposed to take effect on 11/15/2023. The administrator confirmed that the facility rescinded the rent increase letters on 10/03/2023 and the additional charges were never issued. Based on interviews and record review, the facility never charged residents extra for rent and care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Illegal eviction” it was alleged residents were to be evicted if they could not afford the rent increase. This allegation was investigated as part of complaint # 31-AS-20230918143720 and was determined to be unsubstantiated. Five (05) out of five (05) residents interviewed on 10/09/2023 confirmed they had not received eviction notices or been told they were to be evicted. The administrator confirmed the facility never sent out eviction notices. Based on record review and interviews, the facility did not issue illegal evictions. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.


No immediate health and safety hazards were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5