<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610121
Report Date: 10/30/2023
Date Signed: 10/30/2023 01:52:02 PM


Document Has Been Signed on 10/30/2023 01:52 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: 50DATE:
10/30/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ginger Po, Jeffrey Po, Chris Salvador, Ed GalangTIME COMPLETED:
01:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 11:00 a.m. on 10/30/2023 an Informal Conference was held at the Woodland Hills-South Adult and Senior Care Regional Office. This Informal Conference was held to discuss a recent case management visit and to provide guidance to ensure future compliance. Prior to the meeting, Licensee was given the chance to review the facility file.


Present at today's meeting were the following:
· Ginger Po – Licensee/Administrator
· Jeffrey Po – Licensee
· Chris Salvador – Director of Operations/ Co-Administrator
· Edgar Galang – Co-Administrator
· Denise Isfeld – Legal Council for the facility
· Angela Kendrick – Regional Manager (RM)
· Naira Margaryan - Licensing Program Manager (LPM)
· Nicholas Reed - Licensing Program Analyst (LPA)

The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 197610121
VISIT DATE: 10/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
BRIEF HISTORY: The facility has been in operation since licensure on 02/03/2021. The facility is in good standing with the Department. On 09/29/2022, LPM Margaryan and LPA Reed conducted an unannounced case management visit in response to an incident report and death report submitted by the facility. The reports involved an alleged altercation between Resident #1 (R1) and Resident #2 (R2). Both residents requiring medical attention due to severe injuries. R1 experienced rib pain, and R2 was found bleeding and unresponsive and passed away days later at the hospital. Interviews, record review, and observations from the case management visit on 09/29/2023 revealed multiple concerning elements regarding the facility’s compliance to Title 22 and other regulations.

LPA and LPM explained the concerns discovered during the case management visit on 09/29/2023:
  • The proximity of the facility’s smoking balcony on the second floor to the activity room and resident rooms.
  • At least one (01) resident was observed smoking in a bedroom. A deficiency is cited today for violation of 87464(f)(1) based on observations of LPA and LPM at approximately 12:00 p.m. on 09/29/2023.
  • Insufficient care for R2 and Insufficient level of care for R1 and other residents experiencing problems with alcohol.
  • R1’s physician’s report being unsigned. A deficiency is cited today for violation of 87458(a) based on record review at approximately 11:30 a.m. on 09/29/2023.

LPM Margaryan discussed the stipulations of the ALWP requiring a microwave and television in a participating resident's room. The facility must maintain a waiver from the resident if they wish to forgo these requirements or live in a shared room.

Jeffrey spoke of the amenity form where a resident waives their right to certain amenities. Chris Salvador presented documentation for R1 and R2 showing their Amenity Forms waiving their rights to a private room, refrigerator, and microwave.

RM Kendrick requested a roster of residents participating in the ALWP be sent to LPA Reed.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/30/2023 01:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 197610121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2023
Section Cited
CCR
87458(a)

1
2
3
4
5
6
7
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee has agreed to review all resident medical assessments and files and ensure all files are complete. Licensee provided a bulleted list of all resident files to be reviewed during the meeting. Deficiency is cleared. LPA to conduct a POC visit by 11/30/2023 to check resident file completion.
8
9
10
11
12
13
14
Based on record review, the license did not comply with the section cited above in 1 out of 52 medical assessments which poses a potential Health, Safety, or Personal Rights risk to residents care.
8
9
10
11
12
13
14
Type B
11/30/2023
Section Cited
CCR87464(f)(1)

1
2
3
4
5
6
7
87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined... "Maintenance of house rules for the protection of residents"
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee has agreed to speak with and remind all residents of necessity to adhere to house rules during a Resident Council meeting. Licensee will provide documentation of the meeting(s) by the POC due date.
8
9
10
11
12
13
14
Based on observations, the licensee did not comply with the section cited above in at least 1 out of 52 residents which poses a potential Health, Safety, or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 197610121
VISIT DATE: 10/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee Ginger explained the ALW resident acceptance process. Chris noted the DHCS inspection for the ALWP took place approximately 2 - 4 months ago.

LPM Margaryan and Co-Administrator Salvador discussed possible facility adjustments and collaboration with the Department of Health Care Services (DHCS) to comply with ALWP requirements.

LPM Margaryan then discussed the licensee's responsibility to meet all residents' needs, including residents who have documented instances involving alcohol use. Counseling, verbal warnings, discussion, documentation, updating care plans, and all reasonable steps should be taken prior to considering eviction.

LPM Margaryan then discussed observations from the Case Management visit on 09/29/2023 in which LPM observed a resident smoking inside of a resident room. Additionally, the second floor smoking balcony was determined to be too close to a resident's room.

Co-Administrator Salvador addressed the smoking balcony history, along with the purpose for the second floor patio being accessible to second floor residents. All parties collaborated to determine a more appropriate location for residents to smoke, but a solution was not found today.

Licensee Ginger discussed future plans for a portion of the second floor to be designated for the Memory Care unit. LPM Margaryan discussed the details of the plan to ensure proper supervision is afforded to residents.

Chris mentioned the ongoing eviction process of Resident #3 (R3), and LPA and LPM confirmed to representatives the legality of the eviction.

LPM Margaryan reiterated the importance of the completion and current status of all resident files, including but not limited to medical assessments, admission agreements, needs and service plans, and other necessary files. Especially important was updating the files of residents with histories of alcohol and substance abuse to ensure the facility is providing all necessary services for the residents' health and safety.

Today, two (02) deficiencies are issued for violations discovered from the 09/29/2023 Case Management visit.
Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4