<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609786
Report Date: 08/03/2022
Date Signed: 08/03/2022 05:20:23 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
02/22/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-NP-20220222171126
FACILITY NAME:WOODLAND HILLS RETIREMENT HOMEFACILITY NUMBER:
197609786
ADMINISTRATOR:KALISTRATOV, SERGUEIFACILITY TYPE:
740
ADDRESS:24301 OXNARD STTELEPHONE:
(818) 564-4381
CITY:WOODLAND HILLSSTATE: ZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Irina FriedTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to change resident's clothes
Staff failed to reposition resident
Staff failed to provide comfortable accommodations for the reside
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit to this facility. The LPA met with staff Irina Fried and explained the reason for the visit. The Administrator Serguei Kalistratov was not present.

During the initial visit conducted on 3/1/2022, LPA’s Elsie Campos and Ashley Smith interviewed a resident's responsible party at 2:44 p.m., interviewed residents at 1:45 p.m., and 1:59 p.m., and, interviewed staff at 3:12 p.m., 3:27 p.m. and 3:46 p.m. The LPA's also obtained documents pertinent to the investigation. During today’s visit the LPA, interviewed staff at 3:10 p.m. and 3:18 p.m., interviewed residents at 3:30 p.m., 3:40 p.m. and 4:15 p.m. and obtained additional documents at 4:28 p.m.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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 5
Control Number 29-NP-20220222171126
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: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786
VISIT DATE: 08/03/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff failed to change resident’s clothes
It was alleged that staff, are not changing the resident’s clothes. Interview with Resident #1 (R1) revealed that they would be left in the same clothes for extended periods of time, but R1 did not specify the time frame. Information obtained from interviews with responsible parties who had been in the facility, claimed that R1 was observed to be in the same clothes when they would visit but could not confirm if it was clean or not. During the 3/1/2022 visit, R1 was in the process of moving and appeared to be in clean clothes. Further interviews claimed that residents are being changed daily. Staff #2 (S2) stated that Resident #2 (R2) refuses to wear additional clothes but sometimes is unable to persuade R1 to wear something different. During today’s visit residents appeared well groomed and in clean clothes. Based on interviews which were conducted, there is insufficient evidence to support the allegation that staff failed to change the resident’s clothes. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation: Staff failed to reposition resident


It was alleged that resident is not being turned regularly. Interviews with staff revealed that facility staff reposition residents that require repositioning as needed and every two hours. Interviews with staff revealed that all facility staff are trained in repositioning. Interviews with facility staff revealed that staff were able to move/reposition R1 who required to be taken to the bathroom for showers and occasional toileting. Interviews with residents confirmed that staff are repositioning them as needed and every two hours. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation: Staff failed to provide comfortable accommodations for the resident
It was alleged that staff, failed to provide comfortable accommodations for the resident. The complainant alleged that R1 reported that a space heater was left in their room making it extremely hot. Interviews with R1 denied allegations that a space heater was ever left however an overhead central heating system would occasionally be turned on by a senile resident. R1 confirmed that if the temperature would get uncomfortable that staff would adjust it. Further interviews confirmed that facility temperature is comfortable and remains comfortable throughout the day and night. During today's complaint visit, the LPA observed the facility to have the thermostat set a comfortable temperature of 75 degrees Fahrenheit. Based on the investigation, there is insufficient evidence to support the claim that staff failed to provide comfortable accommodations for the resident. This allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/22/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-NP-20220222171126

FACILITY NAME:WOODLAND HILLS RETIREMENT HOMEFACILITY NUMBER:
197609786
ADMINISTRATOR:KALISTRATOV, SERGUEIFACILITY TYPE:
740
ADDRESS:24301 OXNARD STTELEPHONE:
(818) 564-4381
CITY:WOODLAND HILLSSTATE: ZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Irina FriedTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff fell asleep in resident's room
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit to this facility. The LPA met with staff Irina Fried and explained the reason for the visit. The Administrator Serguei Kalistratov was not present.

During the initial visit conducted on 3/1/2022, LPA’s Elsie Campos and Ashley Smith interviewed a resident's responsible party at 2:44 p.m., interviewed residents at 1:45 p.m., and 1:59 p.m., and, interviewed staff at 3:12 p.m., 3:27 p.m. and 3:46 p.m. The LPA's also obtained documents pertinent to the investigation. During today’s visit the LPA, interviewed staff at 3:10 p.m. and 3:18 p.m., interviewed residents at 3:30 p.m., 3:40 p.m. and 4:15 p.m. and obtained additional documents at 4:28 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-NP-20220222171126
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: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786
VISIT DATE: 08/03/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff fell asleep in resident’s room
It was alleged that staff fell asleep in the resident’s room while on shift. Interview with Resident #1 (R1) revealed that Staff #1 (S1) had fallen asleep more than once in their room on a couch located in the room, while conducting routine care checks. Information obtained from interviews with responsible parties who had been in the facility, confirmed claims that staff were observed sleeping in common spaces. S1 confirmed that they sleep at the facility on a couch in the living room or rests in the daytime on a bed outside. Additional staff interviews confirmed that staff do sleep in the living room couch during the night shift. During the 3/1/2022 visit, the LPA’s did not observe a designated staff room. The LPA discussed personal accommodations relating to staff and residents with Staff Irina Fried. Based on the investigation, there is sufficient evidence to support the claim that staff fell asleep in resident’s room. This allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-NP-20220222171126
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: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2022
Section Cited
CCR
87307(a)(B)
1
2
3
4
5
6
7
87307(a)(B) Personal Accommodations and Services Living accommodations... shall ... provide...privacy for the residents, staff...(B) No room commonly used for other purposes shall be used as a sleeping room...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator has agreed to do the following:
1. Submit a statement to CCL, stating the appropriate use for common rooms and how they will be utilized. Submit Statement of Understanding by 8/10/22.
8
9
10
11
12
13
14
Based on observation, the licensee failed to ensure that common areas were used appropriately, as staff confirmed sleeping on the couch, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5