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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609889
Report Date: 10/21/2021
Date Signed: 10/21/2021 02:24:12 PM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2021 and conducted by Evaluator Eleza Jackson
COMPLAINT CONTROL NUMBER: 31-AS-20211013144148
FACILITY NAME:PEARL OF WEST HILLS, INCFACILITY NUMBER:
197609889
ADMINISTRATOR:IRINA, KARBACHINSKIYFACILITY TYPE:
740
ADDRESS:23427 VICTORY BLVDTELEPHONE:
(818) 854-6306
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yell at residents
Staff does not allow resident's to leave the facility
Staff confiscated resident's clothing
Facility does not have planned activities
Staff are not following COVID protocol
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(s) Eleza Jackson and Wendell Smith conducted an unnannounced complaint visit to investigate the allegations above. LPA's met with the facility administrator and explained the reason for this visit.
Upon entry to the facility a physical plant tour was conducted from approximately 9:50am-10:10am to ensure no immediate health and safety issues were present. LPA's did not observe any immediate health and safety issues.
Staff yell at residents
It is alleged that the facility administrator have yelled at residents in the facility. LPA's conducted interviews with residents, administrator, and facility staff from approximately 10:20-11:20am. Interviews revealed that on occassion the facility administrator had yelled at resident # 1(R1) when R1 was smoking in their room and in the kitchen area. Administrator admitted to this happening and facility residents stated they overheard a staff yelling at a resident but could not state which staff was doing the yelling. Based on the information obtained through interviews this allegation is deemed Substantiated at this time.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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 8
Control Number 31-AS-20211013144148
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
VISIT DATE: 10/21/2021
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
Staff does not allow resident's to leave the facility
It is alleged that residents are not allowed to leave the facility without permission. Interviews were conducted with residents and staff from approximately 10:20-11:20am. Interviews revealed that residents didn't feel they were able to leave the facility without permission from staff or unless they were supervised by staff. Interviews revealed that some residents do not require supervision to be outside of the facility independently. Based on the information obtained through interviews this allegation is deemed Substantiated at this time.

Staff confiscated resident's clothing
It is alleged that the administrator confiscated R1's clothing so they could not leave the facility. Interviews were conducted with the administrator regarding this allegation. Administrator stated that anytime R1 would wear clothes they would leave the facility and that due to R1's health condition their safety was in jeopardy. R1 was kept in a hospital gown or diaper while in the facility which was witnessed by visitors to the facility. Based on the information obtained through interviews this allegation is deemed Substantiated at this time.

Facility does not have planned activities
It is alleged that the facility does not have planned activities. LPA's conducted interviews with residents and facility staff from approximately 10:20-11:20am. Interviews with residents and the administrator reveal that the facility does not have planned activities for the residents. There are some board games or television for residents to partake in but nothing planned. Based on the information obtained through interviews this allegation is deemed Substantiated.

Staff are not following COVID protocol
It is alleged that the staff are not checking all visitors temperatures when they visit the facility to check for signs of covid. LPA's conducted interviews with facility staff regarding this allegation. Facility staff admitted to on a few occasions on not checking a visitors temperature when they came to the facility to check on residents. During today's visit LPA's temperatures were checked before starting the visit. Based on the information obtained through interviews this allegation is deemed Substantiated at this time.

All deficiencies cited on LIC 9099 D. Appeal Rights explained, Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2021 and conducted by Evaluator Eleza Jackson
COMPLAINT CONTROL NUMBER: 31-AS-20211013144148

FACILITY NAME:PEARL OF WEST HILLS, INCFACILITY NUMBER:
197609889
ADMINISTRATOR:IRINA, KARBACHINSKIYFACILITY TYPE:
740
ADDRESS:23427 VICTORY BLVDTELEPHONE:
(818) 854-6306
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not provide residents with snacks between meals
Staff are not able to communicate with residents
Facility does not have a poster displaying information on the appropriate reporting agency
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(s) Eleza Jackson and Wendell Smith conducted an unnannounced complaint visit to investigate the allegations above. LPA's met with the facility administrator and explained the reason for this visit.
Upon entry to the facility a physical plant tour was conducted from approximately 9:50am-10:10am to ensure no immediate health and safety issues were present. LPA's did not observe any immediate health and safety issues.
Staff does not provide residents with snacks between meals
It is alleged that snacks are not provided to residents between meals. LPA's conducted interviews with residents and facility staff from approximately 10:20-11:20am. LPA's also conducted a tour of the kitchen to observed the food supply. LPA's observed there to be a sufficient amount of food with many of options. Interviews with residents revealed that they are provided with snacks between meals and have no issue receiving snacks. Based on information obtained through interviews and observations during the visit this allegation is deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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 8
Control Number 31-AS-20211013144148
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
VISIT DATE: 10/21/2021
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
Staff are not able to communicate with residents
It is alleged that facility has staff that are not able to communicate with residents. LPA's conducted interviews with residents and staff from approximately 10:20-11:20am. Interviews revealed that staff #2(S2) does not speak English well but S2 always works with another staff who is able to communicate in English. Information from interviews reveal that on each shift there is a staff that is able to communicate in English. Based on the information obtained this allegation is deemed Unsubstantiated at this time.

Facility does not have a poster displaying information on the appropriate reporting agency
It is alleged that the facility was provided a Long Term Care Ombudsman poster on 9/20/21 but that it has not been posted in the facility. During the physical plant tour done today LPA's observed the Long Term Care Ombudsman poster to be posted by the entry to the facility. Interview with the administrator revealed that it had been posted as soon as it was provided by the Long Term Care Ombudsman. Based on information obtained through observation this allegation is deemed Unsubstantiated at this time.

Exit interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 31-AS-20211013144148
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall submit written statement that no residents will be yelled at and will be talked to appropriately. Copy of written statement will be due by poc due date.
8
9
10
11
12
13
14
Based on interviews conducted it was revealed that R1 was yelled at by the facility administrator which posed a personal rights violation to residents in care.
8
9
10
11
12
13
14
Type B
10/25/2021
Section Cited
CCR
87468.1(a)(6)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities-To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall have a meeting with all residents and explain those that are able to leave the facility without supervision shall be able to without permission. Staff will have a sign in sheet to which residents will sign that meeting too place and copy will be sent to LPA by poc due date.
8
9
10
11
12
13
14
Based on interviews conducted residents were not able to leave the facility at anytime. This poses a potential personal rights violation to residents in care.
8
9
10
11
12
13
14
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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 31-AS-20211013144148
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited
CCR
87468.1(a)(12)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities-To wear their own clothes; to keep and use their own personal possessions.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator will send statement that all residents will be able to wear whatever clothes they choose to and will have access to all of their clothing without interference from facility staff.
8
9
10
11
12
13
14
Based on interviews conducted it was observed and admitted to by the administrator that R1 was not able to wear or have access to their own clothes which is a violation of residents personal rights.
8
9
10
11
12
13
14
Type B
10/25/2021
Section Cited
CCR
87219(a)
1
2
3
4
5
6
7
Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administator shall come up with an activity calendar with input from the residents of various activities that residents will be offered and can participate in. Copy of activity calendar will be sent to LPA by poc due date.
8
9
10
11
12
13
14
Based on interviews conducted facility does not have any planned activities for residents.
8
9
10
11
12
13
14
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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 31-AS-20211013144148
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
87468.2(a)(2)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall have in-service with facility staff on the importance of checking all visitors temperatures. Copy of in-service sign in sheet shall be sent to LPA.
8
9
10
11
12
13
14
Based on interviews conducted staff were not checking all visitors temperatures upon entry to the facility which poses an immediate 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8