197609049-2-21-2024-31-AS-NGID-D32R3L-20240304114005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 02/21/2024
Date Signed: 02/21/2024 06:31:41 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: 35	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Stephanie Oden, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Resident sustained fractures due to staff neglect
Resident's medication is missing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with the Administrator and explained the reason for the visit.

On 07/19/2023, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations, “Resident sustained fractures due to staff neglect." The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator Douglas Real.

On 07/20/23, LPA Panushkina initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but not limited to Admission Agreement (dated: 05/04/22), Physician’s Report (dated: 05/25/2022), Preplacement Appraisal (dated: April 2022) and an Appraisal (dated: 05/04/22)
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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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: 02/21/2024

NARRATIVE

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Investigator, Real, conducted interviews four (4) residents, MedTech and Business Manager on 08/18/23. On 08/21/23, Investigator requested R1’s Medical Records and received on 09/05/23. In addition, Memory Care Director and three (3) staff members were also interviewed on 10/03/23.

Allegation: Resident sustained fractures due to staff neglect.

The investigation findings revealed that R1 had been living at this facility since May 4^th, 2022. Review of R1’s Physician’s Report revealed R1 was diagnosed with COPD and Chronic Respiratory Failure. R1 was ambulatory and was able to care for self. Investigator’s interview with the facility MedTech revealed that on 06/09/23 R1 had an accidental fall in the room and R1’s spouse pressed the pendant for an assistance. MedTech responded to the room and found R1 on the floor. Once assessed by the MedTech, R1 reported some mild pain on a right side near the ribs. Although, 9-1-1 was immediately called and the MedTech encouraged R1 to get checked out at the hospital, R1 refused, but agreed to go to the hospital the following day if the pain continued, in which R1 did. A review of the medical records revealed that on 6/10/2023, at 1218 hours, R1 was seen in the emergency department after a fall and diagnosed with two right rib fractures. Investigators’ interview with R1 revealed that R1 was reaching for something and fell out of the couch. R1 stated that the facility employees provide a good level of care, regularly checked on R1 and responded quickly to R1’s emergency call button. In addition, R1 denied the allegation and did not blame the facility employees or the facility for the fall or the fractured ribs. Lastly, Investigators’ interview with the Business Manager, Memory Care Director, three (3) staff members revealed that the facility staff regularly interacts with the residents, and none have reported any neglect or lack of care by the facility employees. All staff members interviewed denied the allegation. Based on interviews and record reviews this allegation is deemed Unsubstantiated, at this time.

Allegation: Resident's medication is missing

It was alleged that R1’s 12 Norco pills were missing. To investigate this allegation, LPA Panushkina conducted an interview with the Administrator, Resident Service Director, two (2) staff members and six (6) residents, during the initial visit made on 07/20/23. Interviews with the Administrator and a Resident Service Director (RSD) revealed that R1 was able to self-manage his/her own medications.

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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: 02/21/2024

NARRATIVE

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Although, R1’s medications were self-managed by R1, facility provided a lock box and placed it in a kitchen cabinet, in R1’s apartment unit, so that R1 could keep the medications locked. In addition, facility provided a Pro Re Nata (PRN) log to R1 to be able to keep track of when and how many pills were used. However, interview with R1 revealed that most of the time the pain medications were not locked and R1 would forget to initial the PRN log. Moreover, interview with the Administrator, RSD and two (2) staff revealed that R1 had visitors who were able to gain access to R1’s room through the living room sliding door and spend a night, time-to-time. Lastly, all six (6) residents interviewed denied the allegation and expressed no concerns regarding this matter. Based on interviews, observation and record reviews this allegation is deemed Unsubstantiated, at this time.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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