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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 08:13:15 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
07/26/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240726105254
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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Facility does not have sufficient dining rooom staff
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 the facility does not have sufficient dining room staff, as there are no staff to serve residents meals. It was further reported that residents have to flag down staff in order to get assistance and it takes a long time to receive meals.

On 07/31/2024, 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 conducted revealed that there is indeed a shortage of staff in the dining/kitchen department.
Continued from LIC 9099
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
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-20240726105254
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 due to numerous calls off and vacancies, the dining area is short staffed which results in staff having to rush to fulfil residents’ requests and multitask in order to meet the residents needs. The shortage of staff also results in residents having to wait a longer time to be served. Timesheets obtained and reviewed for the time period of 07/15/2024 through 07/30/2024 reflected that the facility is scheduled to have three (3) dining room staff per shift. However, on certain days there was only one (1) dining staff available, therefore, caregivers have to step into assist. Based on the information gathered during the course of the investigation, the Department has sufficient evidence to determine that the facility dining area is short staffed. Therefore, the above allegation “facility does not have sufficient dining room staff” 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.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
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-20240726105254
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
87555(b)(18)
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87555(b)(18) General Food Service Requirements.(b)The following food service requirements shall apply:(18) Sufficient food service personnel shall be employed... This requirement was not met as evidenced by:
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ED will ensure to hire more staff. Corporate gave ED the ok to soon hire a host. New implementations will be done before October 10th 2024.
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Based on interviews and record review the licensee did not comply with the regulation above, as there was not a sufficient number of staffing in the dining and kitchen, which poses a potential 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: Valeria ConwayTELEPHONE: (818) 454-0485
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)
Page: 3 of 3