197610121-6-8-2022-31-AS-CHAS-CG5QFN-20220708120813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610121
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:15:19 PM

Unsubstantiated

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
06/07/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220607152225

FACILITY NAME:	WEST HILLS ASSISTED LIVING		FACILITY NUMBER:	197610121
ADMINISTRATOR:	MILLAN, JONATHAN		FACILITY TYPE:	740
ADDRESS:	7055 SHOUP AVENUE		TELEPHONE:	(818) 883-7201
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	90	CENSUS: 53	DATE:	06/08/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Jonathan Millan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was inappropriately touched by another resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit regarding the allegation above. LPA met with the administrator and explained the reason for this visit.
It is alleged that resident #1 (R1) was inappropriately touched by resident #2 (R2) on 6/2/22. LPA spoke with the administrator regarding this allegation and reviewed R1 and R2's facility file from approximately 1-1:40pm. LPA also obtained copies of pertinent information related to the allegation.
LPA conducted interviews with both R1 and R2 regarding the allegation from 1:45-2:25pm. Information from interviews revealed that on 6/2/22 at approximately 9pm that R1 and R2 were talking in R1's room and R2 kissed R1 without permission. R1 then left the room and alerted facility staff regarding what happened. Facility staff assisted R1 back to their room and stayed with R1 in their room to help calm R1 down. R2 had left R1's room by the time R1 was coming back to their room with staff. On 6/3/22 the administrator conducted interviews with R1 and R2 regarding the incident. Administrator completed an Soc 341 and sent it out to law enforcement, Long term Care Ombudsman (LTCO), and licensing. Administrator also contacted the family of R1 and let them know of the incident. Administrator met with R2 and gave R2 a written warning regarding their behavior.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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 2

Control Number 31-AS-20220607152225

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
	VISIT DATE: 06/08/2022

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

Law Enforcement came on 6/7/22 and interviewed both R1 and R2 regarding the incident. A review of R1 and R2's physician report and needs/assessment show that both residents are able to make their own decisions and don't need any kind of special supervision. Based on the information obtained through interviews and review of documentation this allegation is deemed Unsubstantiated at this time. There was no facility negligence that lead to this incident to happen. Exit Interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2