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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197609049
Report Date:
08/08/2022
Date Signed:
08/08/2022 12:35:03 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
02/26/2021
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20210226145436
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:
91
DATE:
08/08/2022
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Liz Gonzalez
TIME COMPLETED:
12:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was assaulted by another resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.
LPA spoke with the administrator by telephone and explained the reason for this visit.
LPA conducted a physical plant tour to ensure no immediate health and safety issues were present and none were observed.
It is alleged that resident # 1 (R1) was assaulted by their roommate in February 2021. Initial visit was conducted on 3/2/21 by LPA Spaeth. Interviews were conducted with staff that day. During today's visit LPA conducted interviews with staff from 10-11am and reviewed R1's facility file from 11-12pm. LPA also reviewed Serious Incident reports that were submitted to licensing by the facility regarding R1. Information from interviews reveal that R1 was hospitalized on 2/25/21 but it had nothing to do with being assaulted by another resident. R1 was also hospitalized on 3/5/21 and 3/27/21 but it had nothing to do with being assaulted by residents or staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2022
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
2
Control Number
31-AS-20210226145436
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:
08/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA interviewed facility staff who worked with R1 and no one witnessed any issues R1 would have with their roommate R2. While R1 hospitalized on 2/25/21 it was noted that R1 did not have any bruising on their body. LPA was unable to interview R1 due to R1 having moved out on 5/1/21. Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2022
LIC9099
(FAS) - (06/04)
Page:
2
of
2