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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 05/08/2021
Date Signed: 05/08/2021 01:46:41 PM



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
08/26/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200826155158
FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 53DATE:
05/08/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Patricia Acosta - Activity DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff 1 (S1) Sexually Abused Resident 1 (R1) by providing shower assistance in a way which was sexually Motivated.
Staff 1 (S1) live streamed herself while giving Resident 1 (R1) a shower
Resident 1 (R1) sustained dramatic change in behavior due to Staff 1 (S1)’s ongoing inappropriate conduct.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. This investigation was conducted by Jose Santana, Investigator with Community Care Licensing Division’s Investigations Branch.

From 9/2/2020 through 10/15/2020, Investigator Santana conducted interviews with various individuals including the complainant, Administrator Dana Anderson, Facility Wellness Director, Facility Business office manager, Medical Social workers from Kaiser, and home health agency, Resident 1 (R1) and other facility residents, facility staff including staff 1 (S1), LAPD officer responding to the facility, LTCO, and R1’s Primary Care Physician.

On 9/11/2020, Investigator conducted review of medical records from Kaiser. On 9/22/2020, Investigator conducted review of home health records which were subpoenaed on 9/18/2020. On 9/21/2020, Investigator conducted review of response from Apple Inc subpoena which was issued on 9/14/2020. On 9/24/2020, Investigator conducted review of phone records received from Verizon which was subpoenaed on 9/14/2020.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
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 6
Control Number 31-AS-20200826155158
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: 05/08/2021
NARRATIVE
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 On 9/30/2020, Investigator conducted review of Body Camera footage which was subpoenaed on 9/21/2020
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Staff 1 (S1) Sexually Abused Resident 1 (R1) by providing shower assistance in a way which was sexually Motivated.

Regarding the allegation listed above, Investigator Santana conducted interview of S1 and other facility staff as well as R1. Additionally, Investigator conducted review of LAPD body camera footage interview of R1. Information obtained revealed the following: When R1 was interviewed by LAPD, R1 confirmed that staff was in fact naked when rendering shower assistance, however, R1 denied that S1 acted inappropriately or in a sexually motivated manner. Other staff who witnessed the incident denied seeing S1 touching R1 inappropriately or make any attempts to conceal her actions. S1 also denied that the incident had a sexual intent. Based on the information obtained the investigator did not obtain any information that indicated the incident had a sexual intent therefore the allegation of sexual abuse is Unsubstantiated.

Staff 1 (S1) live streamed herself while giving Resident 1 (R1) a shower.

It was alleged that S1 was live-streaming R1 in the shower. Information obtained during the investigation revealed that S1 was on a phone call with her partner. Based on interview with S1 and Verizon phone records, it is believed that S1 made a call to her partner at 6:15 am while escorting R1 to the bathroom. S1 then placed the phone on the bathroom sink while removing her clothing. S1 remained on the phone call until about 6:58 pm (duration of the shower). S1 stated the phone call was unrelated to the shower however acknowledged using bad judgment in handling her phone during work hours. Based on the information obtained, the allegation is Unsubstantiated.

Resident 1 (R1) sustained dramatic change in behavior due to Staff 1 (S1)’s ongoing inappropriate conduct.

Regarding the allegation listed above, IB investigator conducted interview with administrator and facility staff. Additionally, Investigator Santana subpoenaed and reviewed medical records from Kaiser as well as internal incident reports and Physician’s communication logs. Records reviewed revealed that R1 had begun refusing showers, falling, or otherwise ending up on the floor prior to start of S1’s employment by the licensee. Records reviewed and interviews conducted did not indicate that these incidents occurred when S1 started working at the facility.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
08/26/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200826155158

FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 53DATE:
05/08/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Patricia Acosta - Activity DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Conduct Inimical: Staff 1 (S1) gave resident 1 (R1) a shower while wearing only briefs.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. This investigation was conducted by Jose Santana, Investigator with Community Care Licensing Division’s Investigations Branch.

From 9/2/2020 through 10/15/2020, Investigator Santana conducted interviews with various individuals including the complainant, Administrator Dana Anderson, Facility Wellness Director, Facility Business office manager, Medical Social workers from Kaiser, and home health agency, Resident 1 (R1) and other facility residents, facility staff including staff 1 (S1), LAPD officer responding to the facility, LTCO, and R1’s Primary Care Physician.

Regading the allegation above: It was reported that facility staff witnessed S1 wearing nothing but briefs on 8/24/2020 while assisting R1 with a shower. During the investigation, Investigator Santana conducted interviews with various facility staff, including but not limited to S1 and the three (3) staff who witnessed the incident. Initially when interviewed, S1 initially stated that S1 provided shower assistance to R1 while wearing a gown.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
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 6
Control Number 31-AS-20200826155158
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: 05/08/2021
NARRATIVE
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When IB investigator informed S1 that witness statement differed greatly from what was described, S1 amended her statement. S1 admitted to removing her clothing, however stated it was to prevent the clothes from getting soiled/wet. When interviewed, S1 acknowledged that such a practice would not be sanctioned by the facility and is considered inappropriate. Therefore, the allegation that S1 engaged in conduct inimical by giving R1 a shower wearing only briefs is Substantiated.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

During the visit LPA spoke with the Administrator Lilit Chaparyan via telephone who designated Patricia Acosta the Activity Director to sign for the reports. Ms. Chaparyan was notified of the findings of the investigation and a discussion was held regarding the plan of correction.

Exit interview conducted, copy of report and appeal rights emailed to the administrator

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20200826155158
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2021
Section Cited
CCR
87777(a)(2)
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The Department may prohibit an individual from being employed or allowed in a licensed facility as specified in Health & Safety Code Sections 1569.58 & 1569.59 (a)The department may prohibit any person from being a member of the board of directors, an executive director, a board member, or an officer of a licensee, or a licensed facility by licensee from employing, or
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LPA spoke with the administrator via telephone who stated that she will provide in service training to all staff. Verification of staff training with the topics covered will be submitted as POC.
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continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of any employee, prospective employee, or person who is not a client who has: (2) Engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of State of CA.
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Administrator will submit the date that training will be submitted by 5/10/2021 and verification of staff training by 5/18/2021
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20200826155158
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: 05/08/2021
NARRATIVE
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Records reviewed also revealed that R1 was more resistant to showering during the second half of June 2020, however the records do not indicate that S1 was providing shower assistance to R1 at that time. When interviewed S1 denied assisting R1 with showers prior to 8/24/2020. Other information obtained revealed that R1 was found on the floor approximately ten (10) times after S1 was hired, rather than expressing agitation the incidents suggest a decline in R1’s functional abilities. R1 started receiving physical therapy from a home health agency to address this concern. Based on the information obtained, this allegation is Unsubstantiated at this time.

During the visit LPA spoke with the administrator Lilit Chaparyan via telephone. Administrator was notified of the findings of the investigation. During the phone call Ms. Chaparyan designated Patricia Acosta the Activity Director to sign for the reports.

Exit interview conducted with the administrator via telephone and copy of report emailed.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6