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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 04:32:49 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 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:
04:35 PM
ALLEGATION(S):
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5
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8
9
Staff left residents in wet briefs for an extended period of time
Facility is malodorous
Staff are not ensuring that the facility is free of pests
INVESTIGATION FINDINGS:
1
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3
4
5
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7
8
9
10
11
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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 the designee and disclosed the reason for the visit.

To investigate the allegations above, LPA conducted an initial visit on 09/13/2023 and interviewed the administrator at 10:05 a.m., Staff #1 (S1) at 11:10 a.m., memory care director at 11:30 a.m., Staff #2 (S2) at 12:45 p.m., Resident #1 (R1) at 12:15 p.m., Resident #2 (R2) at 12:30 p.m., and Resident #3 (R3) at 12:40 p.m. and toured the facility at 12:30 p.m. LPA conducted a subsequent visit on 09/20/2023 and interviewed Resident #4 (R4) at 1:35 p.m. and Resident #5 (R5) at 1:55 p.m. LPA conducted another subsequent visit on 10/09/2023 and interviewed Staff #3 (S3) at 11:15 a.m., Staff #4 (S4) at 11:30 a.m., and Staff #5 (S5) at 11:45 a.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 also 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: 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
09/07/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230907123643

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:
04:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly trained
Staff are not meeting residents’ laundry needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
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 on 09/13/2023 and interviewed the administrator at 10:05 a.m., Staff #1 (S1) at 11:10 a.m., memory care director at 11:30 a.m., Staff #2 (S2) at 12:45 p.m., Resident #1 (R1) at 12:15 p.m., Resident #2 (R2) at 12:30 p.m., and Resident #3 (R3) at 12:40 p.m. and toured the facility at 12:30 p.m. LPA conducted a subsequent visit on 09/20/2023 and interviewed Resident #4 (R4) at 1:35 p.m. and Resident #5 (R5) at 1:55 p.m. LPA conducted another subsequent visit on 10/09/2023 and interviewed Staff #3 (S3) at 11:15 a.m., Staff #4 (S4) at 11:30 a.m., and Staff #5 (S5) at 11:45 a.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 also 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: 2 of 5
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: 01/09/2024
NARRATIVE
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Regarding the allegation “Staff are not properly trained” it was alleged S5 improperly provided insulin to Resident #4 (R4) resulting in low blood sugar. Interview with R4 at 1:05 p.m. on 10/09/23 revealed that around 9:00 p.m. on 09/01/2023, S5 provided insulin to R4 without checking R4’s blood sugar first. R4 felt lethargic and fell a few hours later. R4’s roommate, Resident #5 (R5) witnessed and confirmed the events to LPA at 1:20 p.m. on 10/09/2023. At 4:00 p.m. on 12/06/2023 S5 told LPA due to short staffing S5 was called to work with R4. R4 demanded they have their insulin many times, and to respect R4’s personal rights, S5 did provide insulin to R4. S5 was unable to test R4’s blood sugar as there were no more blood glucose test strips. S5 admitted they should have tested R4's blood sugar level prior to assisting with insulin. Based on interviews, S5 was not properly trained in medication assistance for R4. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 809-D page.

Regarding the allegation “Staff are not meeting residents’ laundry needs” it was alleged memory care residents were not provided laundry services for over a week. The interviews conducted with R1, R2, and R3 revealed no pertinent information to the investigation. The memory care director noted that when they were on leave in August 2023, the administrator provided insufficient direction to memory care staff during that time. Since then, the memory care director has ensured that staff check laundry on a daily basis. S1 and S2 stated they clean laundry every week for each resident. S3 confirmed that when the memory care director was away, Resident #6 (R6) did not get their laundry done. S4 confirmed that laundry baskets were full and laundry needed to be done. LPA checked five (05) out of eight (08) resident laundry baskets during the 09/13/2023 facility tour. Laundry baskets were not full and new signs were posted on closets which stated “Attention all staff: Please keep closet organized”. Based on interviews, the facility did not provide adequate laundry service. The facility has made adjustments since then and corrected the issue. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 809-D page.

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: 3 of 5
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
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(d)
1
2
3
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87411 Personnel Requirements - General (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill... as appropriate for the job assigned
This requirement is not met as evidenced by:
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2
3
4
5
6
7
Licensee has agreed to conduct an in-service training for all staff assisting residents with medication. Documentation of 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 one (01) employee which poses a potential Health, Safety, or Personal Rights risk to residents in care.
8
9
10
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14
Type B
01/19/2024
Section Cited
CCR
87307(a)(3)(F)
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7
87307 Personal Accommodations and Services (a) ...The facility shall be large enough to provide... (3) Equipment and supplies necessary for... (F) Basic laundry service (washing, drying, and ironing of personal clothing).This requirement is not met as evidenced by:
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3
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Licensee has agreed to conduct an in-service training for the cited section. Documentation of training due by POC due date.
8
9
10
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14
Based on interviews, the licensee did not comply with the section cited above in one (01) resident which poses a potential Health, Safety, or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
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: 4 of 5
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: 01/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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21
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25
26
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28
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32
Regarding the allegation “Staff left residents in wet briefs for an extended period of time” it was alleged that on the night of 09/06/2023, the facility ran out of diapers to accommodate memory care residents’ incontinence needs. Residents allegedly affected were R1, R2, R3 and three other residents. The interviews conducted with R1, R2, and R3 revealed no pertinent information to the investigation. Interviews with the memory care director and staff revealed residents were not and are never left in wet diapers. The memory care director stated staff are to change resident diapers every 2 hours or as needed, and the facility maintains an extra supply of diapers in storage. S3 and S4 noted the facility was low on diapers for a period of time in August and September 2023, but no residents were left in soiled diapers. Based on interviews, residents and staff could not confirm the allegation to be true. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Facility is malodorous” it was alleged resident rooms in the memory care section smelled bad. LPA did not detect any foul odors during the facility tour on 09/13/2023 or today. Residents interviewed on 10/09/2023. The interviews conducted with R1, R2, and R3 revealed no pertinent information to the investigation. Five (05) out of five (05) other residents interviewed on 10/09/2023 did not tell of any bad odors in the facility. The memory care director, S3, and S5 did not detect any foul odors. S4 mentioned residents occasionally have accidents, so the facility puts plug-in air fresheners in rooms and S4 sanitizes rooms when smelling bad. Based on interviews and facility tours, residents, staff, and LPA did not smell any bad odors. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff are not ensuring that the facility is free of pests” it was alleged cockroaches and a spider were observed in the facility. The allegation “Facility kitchen area is not kept free of insects” was substantiated on 02/08/2023 as part of complaint investigation # 31-AS-20230130094323. The facility increased routine fumigation services as part of corrective action. Interviews with residents, staff, memory care director, and administrator revealed nobody has recently seen roaches or spiders in the facility. LPA did not observe any pests during the 09/13/2023 tour or during today’s tour. Based on interviews and observations, the facility is free of pests. 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: 01/09/2024
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