197609049-6-18-2024-31-AS-NMAN-D7GRS8-20240724131620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:42:09 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
07/12/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230712130312

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:	0	CENSUS: 43	DATE:	06/18/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Stephanie Oden/Administrator		TIME COMPLETED:	02:51 PM

ALLEGATION(S):

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Staff violated resident's personal rights
Staff failed to meet resident's needs

INVESTIGATION FINDINGS:

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Licensing program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to deliver findings. The administrator was at the facility. LPA met with the administrator and disclosed the purpose of the visit.

Staff violated resident's personal rights
It was alleged that staff violated resident’s personal rights. To investigation the allegation on 07/19/23, LPA Tihesha Smith conducted a short tour of the facility, interviewed staff, and requested facility records from approximately 12:05 pm to 1:00 pm. R1 is no longer a resident at the facility. During today's visit, LPA Smith interviewed staff and requested records from 11:13-1:00pm. Interview with two (2) of six (6) staff revealed 911 was called due to R1 having an unstageable wound not to resuscitate them. Review of R1’s Physicians Orders for Life Sustaining Treatment (POLST) revealed the following: Do not attempt Resuscitation (DNR) and medical intervention also selected for Comfort-Focused Treatment with Request

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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-20230712130312

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: 06/18/2024

NARRATIVE

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(cont. from 9099)

transfer to hospital only if comfort needs cannot be met in current location.
Based on interview and records review, there is insufficient evidence to support the allegation Staff violated resident's personal rights. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time

Staff failed to meet resident's needs

It was alleged that staff failed to meet resident’s needs due to R1 having a high acuity of needs. Review of R1s hospice documents note care being provided for wounds on Silverado Hospice Care notes. Interviews with two (2) of six (6) staff revealed R1 had wounds. One (1) of six (6) staff revealed R1 wound became stage III and/or unstageable so 911 was immediately called so R1 could receive care for the wounds.

Based on interviews and records review there is insufficient evidence to support the allegation Staff failed to meet resident's needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted/Copy of report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

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