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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609641
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:11:21 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
07/24/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20200724083937
FACILITY NAME:COMMONS AT WOODLAND HILLS, THEFACILITY NUMBER:
197609641
ADMINISTRATOR:STEWART, BRADLEYFACILITY TYPE:
740
ADDRESS:21711 VENTURA BLVDTELEPHONE:
(801) 815-0808
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 103DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Hannah Meyers - Executive Director TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not follow resident's care plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegation. LPA met with Executive Director Hannah Meyers and explained the reason for the visit.

During the course of the investigation, LPA Kristin Heffernan conducted a physical plant tour virtually on 07/30/2020, interviewed Administrator and requested pertinent documentation relevant to the investigation. On 11/29/2021 LPA Brian Balisi conducted physical plant with Administrator, Interviewed Staff and reviewed and obtained copies of pertinent documents relevant to the investigation. Today LPA interviewed Hannah and reviewed pertinent documents relevant to the investigation.

It was alleged that facility staff did not follow resident's care plan due to Resident 1 (R1) being transferred to the hospital. LPA's record review of Hospice records, hospital discharge summary , and nurse's notes as well as interviews with staff revealed that on 07/21/2020, approximately (15) residents tested positive for COVID-19 in memory 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: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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 29-AS-20200724083937
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: 10/21/2022
NARRATIVE
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Continued from 9099

On 07/22/2020, R1 was admitted to the hospital as R1 was experiencing a fever of 100.8 degrees Fahrenheit , shortness of breath and general weakness. As this was during the height of COVID-19 pandemic the facility admitted R1 to the hospital as a precautionary measure to protect the health and safety of R1 and other residents in care. Records review further revealed R1 tested positive for COVID-19. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that facility staff did not follow resident's care plan. Therefore, the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2