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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609889
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:57:00 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
03/01/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220301152954
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:
03/02/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility does not have any planned activities
Facility does not have enough staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with staff and explained the reason for this visit. LPA spoke with the administrator by telephone and explained the reason for the visit. Administrator stated they would come to the facility later due to being in the emergency room with another client.
LPA toured the physical plant of the facility from 9:45-10:10am to ensure no immediate health and safety issues.
It is alleged that the facility does not have any planned activities. LPA conducted interviews with residents from 10:15-10:45am regarding this allegation. LPA had previously conducted interviews with the Long Term Care Ombudsman (LTCO) and the administrator regarding this allegation. Information obtained through interviews reveal that there were no planned activities for the residents. Therefore this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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 3
Control Number 31-AS-20220301152954
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: 03/02/2022
NARRATIVE
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It is alleged that facility does not have enough staff to meet the needs of all the residents. LPA had previously conducted interviews with residents, staff, and LTCO prior to coming to this visit. LPA also had conducted a case management visit on 2/16/22 where interviews were conducted. Based on the information obtained through interviews this allegation is deemed Substantiated. Facility does not have enough staff to support the needs of all of their residents. Resident #1 (R1) is not able to leave the facility for a walk or go on outings due to lack of staff. Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220301152954
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2022
Section Cited
CCR
87411(a)
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Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by:
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Administrator stated they have hired additional staff. A staff schedule will be sent to LPA to clear deficiency.
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Based on interviews conducted facility did not have enough staff to meet all resident needs.
This poses a potential health and safety risk to residents in care.
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Type B
03/02/2022
Section Cited
CCR
87219(a)
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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:
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Corrected before visit. Activity calendar was given to LPA.
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Based on interviews conducted residents did not have planned activities which posed a personal rights violation to residents 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: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3