197609049-9-13-2023-31-AS-NMAN-D5GVWW-20240521164835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 09/13/2023
Date Signed: 09/13/2023 04:32:01 PM

Unsubstantiated

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
09/07/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230907123643

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	CHA, TAMMIE		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 52	DATE:	09/13/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Stephanie Oden		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility is operating without an administrator
Residents sustained unexplained bruising while in care
Staff did not dispose of medication no longer needed

INVESTIGATION FINDINGS:

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At 9:45 a.m. on 09/13/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint investigation. LPA met with the Administrator and disclosed the reason for the visit.

LPA toured the physical plant today at 10:00 a.m., interviewed staff and residents between 10:15 a.m. and 1:00 p.m., reviewed records at 12:00 p.m. and observed residents between 12:15 p.m. and 12:45 p.m.

Regarding the allegation “Facility is operating without an administrator” it was alleged that Staff #1 (S1) was serving as an interim Administrator and was unqualified. Interview with the current Administrator at 10:15 a.m. today revealed that the facility experienced a management change and change of Administrator on 09/01/2023, and S1 was not at Administrator.

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: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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-20230907123643

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: 09/13/2023

NARRATIVE

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Interview with S1 at 11:30 a.m. today confirmed that S1 was not acting as a facility Administrator. Record review at 12:00 p.m. confirmed the current Administrator has a valid and active certificate. Based on interviews and record review, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Residents sustained unexplained bruising while in care” it was alleged Resident #1 (R1) and Resident #2 (R2) had bruises which were not reported by the facility. Interviews with the Administrator at 10:15 a.m. and S1 at 11:30 a.m. today revealed the facility was aware of R1’s bruises and reported them properly to family, physician, and Community Care Licensing on 09/06/2023. Record review at 12:00 p.m. confirmed the facility properly reported R1’s bruises. LPA observed and interviewed R1 at 12:15 p.m. today and R2 at 12:30 p.m. R1’s bruises were healing, but no bruises were visible on R2. R1 could not recall the cause of the bruising. R2 reported no pain or recollection of bruising. Based on interviews, record review, and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff did not dispose of medication no longer needed” it was alleged the medication of Resident #3 (R3) was not properly disposed. Interviews today with the Administrator at 10:15 a.m. and Staff #2 (S2) at 10:40 a.m. revealed the facility was in the process of disposing all extra resident medications. S2 notified the pharmacy on 09/09/2023 and 09/12/2023 that assistance was required for proper disposal as the facility had reached capacity on disposal receptacles. S2 and LPA did not find any medication belonging to R3 in the facility. Record review at 12:00 p.m. today revealed the facility documented all medication disposal properly. Based on interviews and record review, there is insufficient evidence to confirm the validity of 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: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC9099 (FAS) - (06/04)

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