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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609889
Report Date: 12/23/2021
Date Signed: 12/23/2021 03:29:28 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
11/29/2021 and conducted by Evaluator Eleza Jackson
COMPLAINT CONTROL NUMBER: 31-AS-20211129160812
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: 4DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
02:49 PM
ALLEGATION(S):
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STAFF DID NOT SEEK MEDICAL ATTENTION IN A TIMELY MANNER
INVESTIGATION FINDINGS:
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On this day Licening 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.

It is alleged that the facility administrator did not seek medical attention in a timely manner for Resident 1 (R1) in the facility. LPA conducted interviews with resident(s), administrator, and facility staff on 12/01/21 from approximately 10:20-11:20am. Interviews revealed that the Facility Administrator admitted to waiting over 20 days to send R1 to hospital for medical attention. Based on the information obtained through interviews this allegation is deemed Substantiated at this time.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Eleza Jackson
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)
Page: 1 of 2
Control Number 31-AS-20211129160812
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: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical... A plan for incidental medical...shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Administrator will submit a written step by step guide to ensure that facility clients medical needs are met and that residents do not experience neglect.
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This requirement was not met as evidenced by: Based on interviews conducted with administrator and R1 that revealed that the administrator did not receive medical attention in a timely manner which posed an Incidental Medical...violation to resident(s) 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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Eleza Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2