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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610121
Report Date: 06/10/2021
Date Signed: 06/10/2021 11:57:18 AM



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
06/02/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210602153205
FACILITY NAME:WEST HILLS ASSISTED LIVINGFACILITY NUMBER:
197610121
ADMINISTRATOR:MILLAN, JONATHANFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:90CENSUS: 43DATE:
06/10/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jonathan MillanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Food served to resident is not of nutritious value
INVESTIGATION FINDINGS:
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An unannounced initial 10 day complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with administrator Jonathan Millan.

When speaking with Mr. Millan LPA requested a copy of the current resident roster and staff schedule.

In regards to the allegation of Food is not of nutritious value, it was reported that the licensee is serving residents food high in carbohydrates and not enough proteins and vegetables. During this visit from 9:30 to 10:30 LPA conducted interview with five (5) resident and reviewed the facility menu. Resident interviewed did not have any concerns/complaints about the food served at the facility. All residents interviewed felt that the facility serves sufficient amount of protein and vegetables with their meals. Based on the information obtained during the course of the investigation the allegation is unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Mr. Millan
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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 3
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
06/02/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210602153205

FACILITY NAME:WEST HILLS ASSISTED LIVINGFACILITY NUMBER:
197610121
ADMINISTRATOR:MILLAN, JONATHANFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:90CENSUS: 43DATE:
06/10/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jonathan MillanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff 1 (S1) did not treat resident 1 (R1) with respect
INVESTIGATION FINDINGS:
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An unannounced initial 10 day complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with administrator Jonathan Millan.

In regards to the allegation listed above, it was reported that staff 1 (S1) got mad at Resident 1 (R1) who wanted his/her medication to be given earlier. During this visit from 9:15 am to 9:30 am LPA conducted interview with S1 and from 9:30 to 10:30 conducted interview with R1 and other facility residents. According to S1 approximately 2 weeks ago, R1 did request his/her medication while she was assisting other residents with their medication. S1 confirmed that she might have lost her patience and asked R1 to wait in his/her room with a higher toned voice. R1 also provided similar information to LPA when Interviewed. Approximately 10:30 am to 10:40 am LPA spoke with the administrator regarding this incident. Based on the information obtained the allegation is substantiated.

Exit interview conducted and copy of report emailed to Mr. Millan
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210602153205
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: WEST HILLS ASSISTED LIVING
FACILITY NUMBER: 197610121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2021
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
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Mr. Millan has agreed to:
1) meet and discuss this incident with staff 1.
2) Schedule personal rights training for all staff.

Training will need to be scheduled within 24 hours and completed by 6/21/2021. Mr. Millan will notify LPA of the scheduled date and submit verification of training when completed.
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Staff 1 (S1) did not comply with the section cited by not according dignity/respect to R1
which posed a immediate personal rights violation to R1.
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3