197609889-12-23-2021-31-AS-NMAN-CN6NUU-20230117094654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609889
Report Date: 12/23/2021
Date Signed: 12/23/2021 02:48:34 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., 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, INC		FACILITY NUMBER:	197609889
ADMINISTRATOR:	IRINA, KARBACHINSKIY		FACILITY TYPE:	740
ADDRESS:	23427 VICTORY BLVD		TELEPHONE:	(818) 854-6306
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 4	DATE:	12/23/2021
		UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:	Irina Karbachinskiy		TIME COMPLETED:	02:47 PM

ALLEGATION(S):

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Staff slapped a resident
Staff does not allow resident to keep personal items in their drawer spaces
Staff did not make medications inaccessible to residents
Staff did not report incidents as required

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Eleza Jackson conducted a facility tour to ensure no immediate health and safety issues were present. LPA Jackson did not observe any immediate health and safety issues. LPA Jackson met with the facility administrator upon her arrival at approximately 1430hrs and explained the reason for this visit.
On 10/21/21 Eleza Jackson and Wendell Smith conducted an unannounced 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.
It is alleged that the facility administrator hits residents in the facility. LPA's conducted interviews with residents and facility staff from approximately 10:20-11:20am and it was determined that staff nor administrator has hit residents. A subsequent telephonic interview was conducted with R1 on 11/02/2021; at approximately 12:56pm and the interview supported the previous interview findings. Based on information obtained through subsequent interviews and interviews conducted at the visit; this allegation is deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza Jackson	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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: 12/23/2021

NARRATIVE

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Staff does not allow resident to keep personal items in their drawer spaces
It is alleged that the facility administrator and staff does not allow resident to keep personal items in their drawer spaces. LPA's conducted interviews with residents and facility staff from approximately 10:20-11:20am and observed resident belongings stored in drawers. Based on information obtained through interviews and observations during the visit this allegation is deemed Unsubstantiated at this time.

Staff did not make medications inaccessible to residents
It is alleged that the facility administrator and staff did not make medications inaccessible to residents.
Upon entry to the facility a physical plant tour was conducted from approximately 9:50am-10:10am. LPAs observed medications labeled, locked, and inaccessible to residents. Based on observations during the visit this allegation is deemed Unsubstantiated at this time.

Staff did not report incidents as required
It is alleged that the staff did not report incidents as required. There were no incidents reported at the visit. Based on information obtained through interviews and observations during the visit this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to administrator with signature.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza Jackson	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

LIC9099 (FAS) - (06/04)

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