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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610121
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:58:03 PM


Document Has Been Signed on 07/07/2022 02:58 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 54DATE:
07/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Chris Salvador & Ginger PoTIME COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit, in regards to an incident report that was submitted to the RO. LPA met with Chris Salvador, Director of Operations (DO), and informed him the reason of the visit.

According to the report, resident # 1 (R1) was eating in the dining room and choked on food. Staff #1 (S1) assisted R1, by performing the heimlich maneuver and dislodging the food from R1's throat. Staff # 2 (S2) also assisted, by performing CPR, and 911 was contacted. Paramedics arrived and assisted the resident, who was laying on the floor and not conscious. R1 was later transported to the hospital, where R1 continues to receive medical treatment. According to the DO, the hospital are assessing R1 and possibly recommending a higher level of care, such as a skilled nursing facility (SNF). The DO will wait for discharge orders and recommendations by the hospital and primary care physician. LPA requested a follow up with R1's condition and discharge plans when they are available.

Exit interview conducted and copy of report.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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 1