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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609641
Report Date: 03/15/2024
Date Signed: 03/15/2024 02:53:31 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20221122131234
FACILITY NAME:COMMONS AT WOODLAND HILLS, THEFACILITY NUMBER:
197609641
ADMINISTRATOR:HANNAH MEYERSFACILITY TYPE:
740
ADDRESS:21711 VENTURA BLVDTELEPHONE:
(818) 999-2610
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 97DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kevan Sidney - Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not provide proper incontinence care to residents in care
Staff do not provide proper medication assistance to residents in care
Residents in care are not provided proper meal service
Staff force residents to do activities

INVESTIGATION FINDINGS:
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**This is the new amended report to update the findings for the report issued on 02/26/2024**
Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Kevan Sidney and explained the reason for the visit. During the visit Sidney had to step out for an appointment, but stated Business Office Director Vanessa Burton can sign in their place.

On 11/28/2022, from 10:00 a.m. – 4:00 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff, residents and reviewed and obtained pertinent documents relevant to the investigation. On 02/23/2024, from 09:45 a.m. – 3:00 p.m., LPA conducted a subsequent complaint visit. During the visit, LPA toured physical plant, interviewed staff, families / responsible parties of residents in care and reviewed and obtained copies of additional documentation relevant to the investigation. Today LPA conducted a medication audit for six (6) residents in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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 6
Control Number 29-AS-20221122131234
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMMONS AT WOODLAND HILLS, THE
FACILITY NUMBER: 197609641
VISIT DATE: 03/15/2024
NARRATIVE
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Continued from 9099
It was reported that staff do not provide proper incontinence care to residents in care as it was alleged that staff leave residents in soiled diapers for an extended amount of time. Interviews with ten (10) staff and six (6) families / responsible parties of residents currently in care reflected that all sixteen (16) individuals interviewed have not observed any residents left in soiled diapers and all (16) did not express any potential or immediate concerns for residents not being provided incontinence care in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff do not provide proper incontinence care to residents in care” is deemed Unsubstantiated at this time.

It was reported that staff do not provide proper medication assistance to residents in care as it was alleged that the Administrator at the time of the complaint, administered Depikote to R1 to control R1’s behavior. Interviews conducted with ten (10) staff revealed that all (10) have only observed the med techs to administer medication to the residents. LPA's interview with six (6) families / responsible parties of residents in care did not express any potential or immediate concerns for residents being administered medications they were not prescribed. LPA’s records review of R1’s Centrally Stored Medication revealed that R1 is not prescribed Depikote. LPA’s medication audit for six (6) residents in care revealed that medications were observed to be properly administered at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff do not provide proper medication assistance to residents in care” is deemed Unsubstantiated at this time.

It was reported that residents in care are not provided proper meal service as it was alleged that residents are not served food in a timely manner and food is not of nutritious value. Interviews conducted with ten (10) staff revealed that all (10) have always observed food arrive to memory care in a timely manner. The food typically offered ranges anywhere from scrambled eggs, soups, sandwiches, hot dogs, various proteins, salads and any other entrees that the resident may request as well. Each staff interviewed have never observed any food that was improperly cooked. LPA observed that the main kitchen has a sufficient supply of fresh fruits and other perishable and non-perishable food in stock.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20221122131234
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMMONS AT WOODLAND HILLS, THE
FACILITY NUMBER: 197609641
VISIT DATE: 03/15/2024
NARRATIVE
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Continued from 9099-C
On 03/15/2024 at approx. 11:45 p.m., in memory care, LPA observed residents were being served Matzoh Ball soup, meatball sandwich, French fries and a mixed vegetable salad. Residents were also offered a variety of items ranging from sandwiches, salads, burgers, rice bowl and pasta. LPA records review of Consultant Dietician Report Card dated February 2024, indicated the food provided and equipment used was sufficient for the population served. LPA's interviews conducted with six families / responsible parties of residents in care revealed that all (6) did not express any potential or immediate concerns that residents were not provided meals in a timely manner and that food was not of nutritious value. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Residents in care are not provided proper meal service” is deemed Unsubstantiated at this time.

It was reported that staff force residents to do activities as it was alleged that the former Administrator forces staff and residents to engage in activities when they are showing the facility to a potential new resident. Interviews conducted with ten (10) staff revealed that all (10) have never been forced to conduct activities with residents and all (10) have never observed other staff forced to conduct activities with residents. LPA's interviews conducted with six (6) families / responsible parties of residents in care revealed that all (6) did not express any potential or immediate concerns that residents or staff were forced to engage in activities. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff force residents to do activities” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20221122131234

FACILITY NAME:COMMONS AT WOODLAND HILLS, THEFACILITY NUMBER:
197609641
ADMINISTRATOR:HANNAH MEYERSFACILITY TYPE:
740
ADDRESS:21711 VENTURA BLVDTELEPHONE:
(818) 999-2610
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 95DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kevan Sidney - Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Resident in care was allowed to leave the facility unassisted

Staff did not follow proper reporting requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This is the new amended report to update the findings for the report issued on 02/26/2024**
Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Kevan Sidney and explained the reason for the visit.

On 11/28/2022, from 10:00 a.m. – 4:00 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff, residents and reviewed and obtained pertinent documents relevant to the investigation. On 02/23/2024, from 09:45 a.m. – 3:00 p.m., LPA conducted a subsequent complaint visit. During the visit, LPA toured physical plant, interviewed staff, families / responsible parties of residents in care and reviewed and obtained copies of additional documentation relevant to the investigation. Today LPA conducted a medication audit for six (6) residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20221122131234
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMMONS AT WOODLAND HILLS, THE
FACILITY NUMBER: 197609641
VISIT DATE: 03/15/2024
NARRATIVE
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It was reported that resident in care was allowed to leave the facility unassisted, as it was alleged that Resident #1 (R1) was able to leave because there was not enough staff present to supervise. LPA's interviews and records review revealed on 08/08/2022, R1 exited the facility via the exit stairwell near R1’s unit. The investigation revealed that prior to the incident, R1 was believed to be in their room. R1 wandered out of their room to the exit door located to the right of R1’s unit. Upon exiting the door, the delayed egress door alarms activated. Staff who were attending to other residents at the time of the incident went to observe both exit passageways, but they did not walk down the stairs or check the exterior of the property in an attempt to locate R1. Staff then contacted the med tech who informed community management, police and family. After calling local hospitals, R1 was found at a nearby hospital located approximately 1 mile from the facility. Records review of R1’s LIC 602 (Physician’s Report) indicated R1 is not able to leave facility unassisted. Based on the information obtained during the investigation, the Department has sufficient evidence to confirm the allegation occurred. Therefore the above allegation “Resident in care was allowed to leave the facility unassisted” is deemed Substantiated at this time.

It was reported that staff did not follow proper reporting requirements, as it was alleged that Resident #2 (R2) sustained a hip fracture and R2’s family was not notified in a timely manner. Interviews conducted and records review reflected that on 09/17/2022 at approx. 07:30 p.m., R2 sustained a fall in their apartment. At that time, R2 did not complain of any pain and was able to move all extremities. Per interviews conducted with R2’s family, the facility did not notify the Responsible Party (RP) of R2 until the next day on 09/18/2022, at 8:10 a.m., when R2 complained of pain in their right hip. At 8:15 a.m., R2’s family/RP was notified of R2’s fall the night before and their change in condition. 9-1-1 was contacted and R2 was transported to the local hospital. Upon admission to the hospital, it was notated that R2 sustained a hip fracture. According to R2’s Heath and Service Evaluation / Appraisal Needs Results and Service Plan dated 04/11/2022, R2 did not require assistance with mobility / ambulation and R2 did not require assistance with escorting. Based on the information obtained during the investigation, the Department has sufficient evidence to confirm the allegation occurred. Therefore the above allegation “staff did not follow proper reporting requirements” is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20221122131234
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMMONS AT WOODLAND HILLS, THE
FACILITY NUMBER: 197609641
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) - To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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Licensee agreed to review regulation cited and provide a statement of understanding to LPA via email by 03/18/2024 EOD. Licensee also stated an elopement drill will be conducted and they will provide LPA a sign-in sheet via email after completion.
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Based on the investigation, the licensee did not comply with the section cited above, as R1 was not properly supervised which led to an elopement, which poses an immediate health and personal rights risk to residents in care.
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Type B
03/29/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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Licensee agreed to review regulation cited and provide a statement of understanding to LPA via email by 03/29/2024 EOD.
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Based on the interviews and records review, the licensee did not comply with the section cited above as the family / responsible party of R2 was not notified about R2’s fall in a timely manner, which poses a potential health and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6