197609061-9-17-2020-31-AS-JAPL-BU8M2Q-20201009091353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609061
Report Date: 09/17/2020
Date Signed: 09/17/2020 08:26:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2020 and conducted by Evaluator Desaree Perera

COMPLAINT CONTROL NUMBER: 31-AS-20200325100914

FACILITY NAME:	WEST VALLEY ASSISTED LIVING		FACILITY NUMBER:	197609061
ADMINISTRATOR:	SAENZ, AMANDA		FACILITY TYPE:	740
ADDRESS:	7055 SHOUP AVENUE		TELEPHONE:	(818) 883-7201
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	90	CENSUS: 50	DATE:	09/17/2020
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Jonathan Millan		TIME COMPLETED:	08:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not protect resident(s) from another resident's harmful behavior while in care
Staff did not intervene in physical altercation between residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Desaree Perera initiated a subsequent complaint to the above facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with administrator Jonathan Millan at 8:07am. The purpose of the telephonic visit is to conclude an investigation initiated by LPA on 04/20/2020. Entrance interview conducted.

It was alleged that staff did not protect resident(s) from another resident’s harmful behavior while in care. During the course of the investigation, LPA conducted interviews with facility staff on 04/06/2020 between 1:45pm and 2:25pm, on 08/06/2020 at 3:50pm and on 08/13/2020 at 10:33am. Interviews were also conducted with residents on 08/13/2020 between 9:10am and 10:20am. Documents relevant to the allegations were also obtained by LPA on 04/06/2020.

Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

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-20200325100914

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WEST VALLEY ASSISTED LIVING	FACILITY NUMBER: 197609061
	VISIT DATE: 09/17/2020

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

Based on information gathered, it has been determined that the Department does not have sufficient information to determine that staff failed to protect resident(s) from another resident’s harmful behavior; therefore, the allegation is deemed UNSUBSTANTIATED at this time.

It was also alleged that staff did not intervene in physical altercation between the residents. During the course of the investigation, LPA conducted interviews with facility staff on 04/06/2020 between 1:45pm and 2:25pm, on 08/06/2020 at 3:50pm and on 08/13/2020 at 10:33am. Interviews were also conducted with residents on 08/13/2020 between 9:10am and 10:20am. Documents relevant to the allegations were also obtained by LPA on 04/06/2020. Based on information gathered, it has been determined that the Department does not have sufficient information to determine that staff did not intervene in physical altercation between the residents; therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Violations that were discovered during the course of the investigation that are unrelated to the complaint will be addressed on a separate Case Management visit at a later time.

Exit Interview conducted telephonically / A copy of report was sent via email for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2