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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609641
Report Date: 09/10/2024
Date Signed: 09/11/2024 08:21:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/16/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240716150247
FACILITY NAME:COMMONS AT WOODLAND HILLS, THEFACILITY NUMBER:
197609641
ADMINISTRATOR:KEVAN SIDNEYFACILITY TYPE:
740
ADDRESS:21711 VENTURA BLVDTELEPHONE:
(818) 999-2610
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 102DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kevan SidneyTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff stole/misplaced residents personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to the facility regarding the above noted allegation. LPA met with Executive Director (ED) Kevan Sidney and explained the reason for the visit.

It was alleged that staff either stole or misplaced residents’ personal property, as the plants that were in Resident #1 (R1s) room was nowhere to be found.

During the course of the investigation, on 07/23/2024, LPA conducted a tour of the physical plant with ED and requested relevant documents. Additionally, between 10:45 A.M. and 1:35 P.M., LPA interviewed twelve (12) residents and six (6) staff members. Interviews with staff revealed that the resident was unable to water the plants, and after a few weeks, the plants died and were discarded by staff.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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 3
Control Number 29-AS-20240716150247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMMONS AT WOODLAND HILLS, THE
FACILITY NUMBER: 197609641
VISIT DATE: 09/10/2024
NARRATIVE
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 Continued from LIC 9099

Interviews further reflected that staff did not inform R1’s Responsible Party (RP) that the plants would be discarded. A file review revealed that the Client/Resident Personal Property and Valuables form (LIC621) used to itemize personal belongings was missing from R1’s file. An interview with the ED regarding this matter was conducted. ED stated that R1 was admitted prior to ED’s hired date, and he was unaware that form used to itemize personal belongings was missing from R1’s file. Moving forward, the ED will ensure that a Resident Personal Property and Valuables form will be kept for all residents, documenting items brought into the facility by residents and their loved ones at any time during their stay. Additionally, ED will speak with all employees to emphasize that no resident’s belongings should be thrown out without the family’s knowledge.

Based on the information gathered during the course of the investigation, the Department has sufficient evidence to determine that personal items were missing from resident’s room. Therefore, the above allegation “Staff stole/misplaced residents’ personal property.” is deemed SUBSTANTIATED at this time.
Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D or LIC 9099-D):

Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240716150247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
87217(b)
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87217 (b) Safeguards for Resident Cash, Personal Property, and Valuables.
Every facility shall... safeguard residents'... personal property and valuables which have been entrusted...The licensee shall give the residents receipts for all... This requirement is not met as evidenced by:
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Administrator will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by POC due date.
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Based on interviews and records review, the licensee did not comply with the section cited above as multiple personal items of R1 went missing while in care, which posed a potential health, safety 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
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