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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609049
Report Date: 08/24/2022
Date Signed: 08/24/2022 01:54:17 PM


Document Has Been Signed on 08/24/2022 01:54 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:FALLBROOK GLEN OF WEST HILLSFACILITY NUMBER:
197609049
ADMINISTRATOR:LILIT CHAPARYANFACILITY TYPE:
740
ADDRESS:6833 FALLBROOK AVETELEPHONE:
(818) 883-4123
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:114CENSUS: 91DATE:
08/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Lilit ChaparyanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Wendell Smith made an unannounced case management visit due to an incident report that was received on 8/15/22 regarding an altercation between two residents (R1, R2) where law enforcement was called. LPA met with the administrator regarding this incident. Information obtained revealed that R2 hit R1 and R1 sustained a bloody nose. R1 was taken to the hospital and came back within an hour. Decision was made to separate two residents and have them switch rooms while speaking with both of their physicians to see if any adjustment in medication needs to be made. Based on the information obtained through interview and documentation review no further action is necessary. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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