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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610121
Report Date: 09/29/2023
Date Signed: 09/29/2023 12:27:07 PM


Document Has Been Signed on 09/29/2023 12:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:WEST HILLS ASSISTED LIVINGFACILITY NUMBER:
197610121
ADMINISTRATOR:GINGER POFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:90CENSUS: 52DATE:
09/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ed GalangTIME COMPLETED:
12:30 PM
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At 8:50 a.m. on 09/29/2023, Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit. LPA and LPM met with the co-Administrator and disclosed the reason for the visit.

Today’s case management visit was conducted after the facility submitted an incident report in which Resident #1 (R1) and Resident #2 (R2) required medical assistance due to severe injuries on the morning of 09/20/2023. R1 experienced rib pain, and R2 was found bleeding and unresponsive. The facility later submitted R2's death report.

LPA and LPM interviewed staff and residents between 9:00 a.m. and 11:00 a.m., reviewed records at approximately 10:15 a.m. and 11:30 a.m., and toured the facility at approximately 10:40 a.m. Multiple deficiencies were observed during the physical plant tour and record reviews including but not limited to deficiencies in personal accommodations and services, admission agreements, physical plant, and basic services.

Deficiencies will be addressed during an Informal Conference held at the Woodland Hills-South Adult and Senior Care Regional Office.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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