197609049-7-20-2023-31-AS-NGID-D32R3M-20240304114005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 07/20/2023
Date Signed: 07/20/2023 04:49:08 PM

Unsubstantiated

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
07/19/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230719153655

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: 59	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Allen C. Boeddeker, Administrator		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Staff did not respond to resident's call button in timely manner
Resident's medication is missing

INVESTIGATION FINDINGS:

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At 11:00 PM, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with the Administrator and requested resident resident and staff roster. LPA also explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 11:20 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Medication Records, etc., relevant to the investigation. At approximately 11:40 AM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 11:45 AM – 3:00 PM, LPA interviewed the Administrator, Resident Service Director, two (2) staff members and six (6) residents.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230719153655

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
	VISIT DATE: 07/20/2023

NARRATIVE

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It was alleged that Staff did not respond to resident's call button in timely manner. To investigate this allegation while interviewing a sample of six (6) residents, LPA randomly tested resident’s pendant and emergency pull cords in their rooms. LPA conducted a random inspection of two (2) pendants and two (2) emergency pull cords, at Assisted Living (AL) Unit, and staff responded within a reasonable time. Interview with the Administrator and Resident Services Director revealed that the facility’s expectation for response time is 10 minutes. Lastly, interviews with five (5) out of six (6) residents revealed that the staff always response within 3-5 minutes. Based on interviews and review of the information received, allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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