197609049-5-10-2022-31-AS-CHAS-CFSUFA-20220627153226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609049
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:55:25 AM

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
09/08/2020 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200908160148

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	DANA ANDERSON		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 83	DATE:	05/10/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Elizabeth Gonzalez		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Lack of supervision resulting in inappropriate interactions between resident's.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to deliver the final findings of the allegation mentioned above. The receptionist informed LPA that the Administrator Lilit Chaparyn was in a resident's meeting and was not available. LPA delivered report to Business Officer Elizabeth Gonzalez. The following was determined:

Allegation: Lack of supervision resulting in inappropriate interactions between residents: On 09/08/2020 a Special Incident Report (SIR) was submitted to Licensing regarding an incident between (2) residents. LPA Yelena Avetisyan obtained facility documents and conducted telephonic interviews from 230pm to 430pm with the Administrator and other interested parties pertaining to the incident. It was also revealed the incident was cross reported to the local police department and the Long-Term Care Ombudsman (LTCO) office. It was alleged that on 08/26/2020 resident # 1(R1) entered the room of resident # 2 (R2), and R1 laid down

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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-20200908160148

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: 05/10/2022

NARRATIVE

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next to R2 and proceeded to inappropriately touch R2’s private parts. R2 reported the incident to R2’s daughter, who then reported the incident to the former Administrator Dana Anderson.

On 09/11/2020, 09/17/2020, 06/25/2021, 04/09/2022, 05/09/2022, and 05/10/2022, from various times, 1030am to 430pm, LPA Tuesday Cabiness obtained additional records, and conducted additional interviews. Through information obtained, it was revealed, R1 had a history of alleged inappropriate behaviors at other facilities, and that staff at R1’s current facility, were aware that R1 was entering resident’s rooms. But it was reported that the visits were consensual amongst R1 and other residents. The police visited the facility on 09/08/2020, in which they conducted interviews and there were no charges made against R1. Although, R1 had a history of inappropriate behavior, from interviews conducted, and not being able to interview staff during the alleged incident, due to them no longer working at the facility, there were no witnesses or evidence to corroborate there was a “Lack of supervision resulting in inappropriate interaction between residents”, therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC9099 (FAS) - (06/04)

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