197609061-5-15-2021-31-AS-CHAS-C4EVX8-20210628164908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609061
Report Date: 05/15/2021
Date Signed: 05/15/2021 05:38:01 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
08/14/2020 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200814100545

FACILITY NAME:	WEST VALLEY ASSISTED LIVING		FACILITY NUMBER:	197609061
ADMINISTRATOR:	MILLAN, JONATHAN		FACILITY TYPE:	740
ADDRESS:	7055 SHOUP AVENUE		TELEPHONE:	(818) 883-7201
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	0	CENSUS: 34	DATE:	05/15/2021
		UNANNOUNCED	TIME BEGAN:	04:20 PM
MET WITH:	Jonathan Millan		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility staff did not provide proper care for resident with dementia
Staff handled resident in a rough manner.
Staff failed to provide adequate food service to resident
Facility staff did not maintain resident’s bathtub.
Staff denied resident from taking a bath
Staff is vindictive towards resident

INVESTIGATION FINDINGS:

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An unannounce subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with med-tech Felix Sator. Administrator Jonathan Millan arrived Approximately 5:15 pm

Regarding the allegation of " Facility staff did not provide proper care for resident with dementia" it was reported that when 911 was called to the facility for Resident 2 (R2) it was Resident 1 (R1) that assisted the paramedics and not the staff. On 8/19/2020 when interviewed R1 stated that she wa not complaining about this but just wanted it on record that it was her who assisted the paramedics. R1 also stated that she does not know . resident is receiving proper care or not. On 8/24/2020 LPA conducted interview with the administrator. According to the administrator when 911 is called for a resident the front desk staff will stay with the EMT's while the med-tech makes copies of pertinent documents for the EMT's to take. According to the administrator R2 does not have a dementia diagnosis. Copies of R1's physicians report were submitted to LPA. Administrayor also confirmed the name of the staff that were with R2 when the EMT's were at the facility. Based on the information obtained the allegation is unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2021

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 3

Control Number 31-AS-20200814100545

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: WEST VALLEY ASSISTED LIVING	FACILITY NUMBER: 197609061
	VISIT DATE: 05/15/2021

NARRATIVE

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Regarding the allegation of " Staff handled resident in a rough manner." it was reported that administrator grabbed and pulled Resident 1 (R1) when he believed that R1 was going to strike another resident. On 8/19/2020 LPA conducted interview with R1. According to R1 another facility resident was tap dancing in the hallway loudly, R1 started banging her cane on the floor and when the resident did not stop R1 began swinging her cane. While R1 was swinging her cane the administrator came out and said that she was hitting another resident. R1 did not indicate that administrator grabbed and/or pulled her at any time. According to R1 she did not his any resident. On 8/24/2020 LPA conducted interview with the administrator according to administrator there was an incident with 2 resident, however it was only 2 residents yelling at each other. R1 was yelling at another resident because he was tap-dancing. Administrator asked R1 to stop yelling and asked other resident to stop the tap-dancing. Per administrator the other resident stopped however R1 contused yelling and walked away. Administrator denied grabbing or pulling resident at any time. According to administrator there were several resident who witnessed the incident. On this day LPA attempted to conduct interviews with Resident 2 (R2) and Resident 3 (R3) however was unable to do so because the resident no longer live at the facility.

Based on the information obtained during the course of the investigation the allegation is Unsubstantiated at this time.

Regarding allegation of " Staff failed to provide adequate food service to resident" it was reported that Resident 1 (R1) is unable to eat meals that contains gluten, On 8/19/2020 when interviewed R1 stated that the center she attends made a mistake and documented that being Gluten free was her choice. Per R1 she believes that they have since corrected the mistake. LPA conducted interview with the administrator on 8/24/2020. According to the administrator R1 chooses to be gluten free and although there is no written order from a physician they do respect her choice. However facility does not have specific gluten free meals they have come to an agreement with R1. According to the agreement the facility has lowered R1's monthly rate so she can purchase certain gluten free foods which she will give to the kitchen to use for her meals. LPA received a signed copy of the agreement Dated 2/6/2020 and signed by Resident 1 (R1).

Based on the information obtained during the course of the investigation allegation is unsubstantiated at this time.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20200814100545

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: WEST VALLEY ASSISTED LIVING	FACILITY NUMBER: 197609061
	VISIT DATE: 05/15/2021

NARRATIVE

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Regarding the allegation of Facility staff did not maintain resident’s bathtub and Staff denied resident from taking a bath. It was reported that R1 is unable to use her bathtub because the administrator refuses to provide her a stopper. On 8/19/2020 LPA conducted interview with Resident 1 (R1). According to R1 she wants to let this allegation go because she has figured out a way to make the water stop. R1 stated that when she asked the administrator for a stopper and was told that it was dangerous to use her shower for a tub. According to R1 she believes that they are not giving her a stopper because of an incident which resulted in the bathroom flooding. On 8/24/2020 LPA conducted interview with the administrator Jonathan Millan. According to the administrator the shower in R1's room is not a full bathtub but more of a "cut up tub" which will allow about 2 feet of water to be filled up. Administrator spoke with staff from a program R1 attends and confirmed that there is no order from the physicians that R1 need to take baths. Administrator also stated that they have spoke to R1 and informed her why a plug cannot be provided to her and they have offered to move R1 to a room that has a full bathtub. However R1 did not want to change rooms because of the increased cost. Based on the information obtained the allegation is Unsubstantiated at this time.

Regarding the allegation of " Staff is vindictive towards resident" On 8/19/2020 LPA conducted interview with Resident 1 (R1) according to R1 the administrator and another facility staff went into her room while she was watching TV. R1 was asked why she was watching resident 2 (R2's) television and was told that they would ask her roommate if she gave her permission to do so. R1 believes that administrator is being vindictive against her because R2 would not mind her using the television. On 8/24/2020 LPA conducted interview with administrator Jonathan Millan. According to the administrator it is their policy to randomly check the rooms of residents who are hospitalized or away from the facility to make sure their roommates are not touching their belongings. Per administrator R1's roommate does not like R1 touching her belonging. On 8/17/2020 when administrator and another staff went to check on R2's belongings they observed that R1 was using her television. R1 stated that she had permission to use the television. Administrator told R1 that they would have to confirm this with R2. Administrator denied that this was done to be vindictive towards R1. Based on the information obtained the allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to the administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2021

LIC9099 (FAS) - (06/04)

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