197609049-10-3-2023-31-AS-NRED-CW9TYY-20231003150930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609049
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:09:58 PM

Document Has Been Signed on 10/03/2023 03:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	STEPHANIE ODEN		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 114	TOTAL ENROLLED CHILDREN: 0	CENSUS: 45	DATE:	10/03/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Stephanie Oden		TIME COMPLETED:	03:10 PM

NARRATIVE

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At 9:10 a.m. on 10/03/2023 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit. LPA and LPM met with staff and later the Administrator and disclosed the reason for the visit. LPA Gina Saucedo joined today's visit at 10:10 a.m. and City Fire Inspector Linsay Peligrini joined at 1:50 p.m.

Today’s case management visit was conducted in conjunction with complaint investigation #31-AS-20230925104214 to address the issues unrelated to the complaint.

During a complaint investigation visit conducted on 09/13/2023, LPA Reed was informed that Staff #1 (S1) made an unwanted sexual advance towards Resident #1 (R1). The incident was reported to the Wellness Director and Former Administrator. However, no actions were taken, and the incident was never reported to the appropriate agencies. On 09/20/2023 LPA Reed spoke with R1 who confirmed that S1 touched R1 inappropriately on more than one occasion. LPA Reed discussed the incidents with the newly hired Administrator who immediately took appropriate actions and suspended S1 from work until further investigation. A deficiency for the previous Administrator’s inadequate reporting is issued on the attached LIC 809-D page.

In addition, LPA Reed noted that up until 09/29/2023, while making phone calls to the facility, the receptionist answered the phone and identified the facility as “Valley Silvertown”. Incident reports sent to CCLD also identify the facility as Valley Silvertown. Several employees were terminated as of 09/01/2023, and the new company improperly took over the facility operation. LPM Margaryan and LPA Reed discussed facility operation while the new application is pending for the “Change of Ownership”. LPM and LPA informed the current Administrator that the facility name is not changed yet and a new application for “Valley Silvertown” is in pending status. Representing the facility as a new facility while the application is pending is considered “conduct Inimical” and may lead to denial of the pending application. Deficiencies for false claims and conduct inimical are issued on the attached LIC 809-D page.

Naira Margaryan	TELEPHONE: (818) 596-4368
Nicholas Reed	TELEPHONE: (818) 669-8178
	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/11/2024 09:16 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/04/2023 08:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Section Cited

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported... within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 10/04/2023
	Plan of Correction
1 2 3 4	The new Administrator appropriately reported the allegation of abuse. Additionally, they conducted an internal investigation and terminated the alleged abuser. Therefore, the deficiency has been cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Naira Margaryan	TELEPHONE: (818) 596-4368
Nicholas Reed	TELEPHONE: (818) 669-8178
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/11/2024 09:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/04/2023 08:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Section Cited

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 10/04/2023
	Plan of Correction
1 2 3 4	The parking lot gate lock was adjusted and unlocked since 10/03/23. Deficiency cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Naira Margaryan	TELEPHONE: (818) 596-4368
Nicholas Reed	TELEPHONE: (818) 669-8178
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/03/2023

NARRATIVE

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During a physical plant tour at 10:15 a.m. today, LPA Reed noticed construction occurring in units on the second floor of the facility. Interview with the Administrator at 10:25 a.m. revealed that residents were notified of the construction, however CCL was not informed prior to its initiation and permits were not obtained prior to construction. Inspector Peligrini confirmed the work performed required permits. Therefore, a deficiency for the unpermitted work is issued on the attached LIC 809-D page.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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