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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609061
Report Date: 08/05/2020
Date Signed: 08/06/2020 03:30:00 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
07/16/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200716093924
FACILITY NAME:WEST VALLEY ASSISTED LIVINGFACILITY NUMBER:
197609061
ADMINISTRATOR:MILLAN, JONATHANFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:90CENSUS: 51DATE:
08/05/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jonathan MillanTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not protect resident from being harassed by another resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Yelena Avetisyan conducted an subsequent telephonic complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was initiated telephonically at 11:00 am with administrator Jonathan Millan.

In regards to the allegation listed above LPA conducted interview with Mr. Millan, Staff 1 (S1) whom the incident was reported to and resident 1 (R1). Interviews conducted revealed that when R1 reported the alleged harassment S1 took immediate action by talking to all parties involved. R1 also confirmed that S1 took immediate action and addressed his/her complaint when he/she reported the incident. On 7/23/2020 LPA requested written statement to be submitted by the administrator and S1. The proper requested information was received on 8/4/2020. Based on the information obtained during the course of the investigation the allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to administrator for signature.
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: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
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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