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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197690045
Report Date: 05/06/2022
Date Signed: 05/06/2022 11:40:35 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211001081014
FACILITY NAME:ELEVATION BEHAVIORAL HEALTHFACILITY NUMBER:
197690045
ADMINISTRATOR:LORI SCOTTFACILITY TYPE:
772
ADDRESS:3855 BRUNSTON COURTTELEPHONE:
(818) 877-0934
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Christina HemmingwayTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Licensee failed to have qualified staff working at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived at unannounced for a subsequent complaint visit. The LPA met with staff and explained the reason for the visit.

During the initial visit on 10/05/2021, the LPA conducted a tour at 12:51 p.m., interviewed staff at 1:27 p.m. and 1:35 p.m., and requested documents. On 3/23/2022, the LPA requested documents and interviewed staff at 11:22 a.m., 11:43 a.m., 11:54 a.m., 12:21 p.m., 2:40 p.m. and 3:10 p.m. During a visit on 4/29/2022, the LPA interviewed staff at 12:56 p.m., 1:21 p.m. and 1:41 p.m., audited files alongside staff, and interviewed a client at 1:16 p.m. In addition, the LPA requested and reviewed timecards and staff training documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
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 5
Control Number 29-AS-20211001081014
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045
VISIT DATE: 05/06/2022
NARRATIVE
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Regarding the allegation: Licensee failed to have qualified staff working at the facility
It was alleged that staff did not receive sufficient training to perform their job duties. Interviews conducted and records review revealed that staff training consists of online training (software: Relias), monthly in-service training, and shadowing. In addition, interviews revealed that in general, staff agreed that their first few weeks at the facility included shadowing more experienced employees coupled with online training. Staff supported claims that they felt sufficiently trained and qualified to perform their job duties. Documents reviewed demonstrated that staff have specific training benchmarks that must be met within 30 days, 90 days, 6 months, and annually. The LPA audited personnel records and identified that the majority of staff received over 20 hours of training in less than a year. The LPA reviewed the facility’s personnel policies, which aligned with the regulatory standard of care staff receiving a minimum of 20-clock-hours of continuing education per year. A review of training documents confirmed that the direct care staff exceeded the minimum requirement. Based off records review and interview, there is insufficient evidence to support the claim that staff are not qualified to work at this facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim, therefore the allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211001081014

FACILITY NAME:ELEVATION BEHAVIORAL HEALTHFACILITY NUMBER:
197690045
ADMINISTRATOR:LORI SCOTTFACILITY TYPE:
772
ADDRESS:3855 BRUNSTON COURTTELEPHONE:
(818) 877-0934
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Christina HemmingwayTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Licensee failed to comply with required staffing ratios
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived at unannounced for a subsequent complaint visit. The LPA met with staff and explained the reason for the visit.

During the initial visit on 10/05/2021, the LPA conducted a tour at 12:51 p.m., interviewed staff at 1:27 p.m. and 1:35 p.m., and requested documents. On 3/23/2022, the LPA requested documents and interviewed staff at 11:22 a.m., 11:43 a.m., 11:54 a.m., 12:21 p.m., 2:40 p.m. and 3:10 p.m. During a visit on 4/29/2022, the LPA interviewed staff at 12:56 p.m., 1:21 p.m. and 1:41 p.m., audited files alongside staff, and interviewed a client at 1:16 p.m. In addition, the LPA requested and reviewed timecards and staff training documents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20211001081014
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045
VISIT DATE: 05/06/2022
NARRATIVE
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Regarding the allegation: Licensee failed to be in the required ratio
It was alleged that the facility failed to maintain the required staffing ratios. The investigation revealed that there needs to be two coaches (ie. non-clinical staff) on each shift, which would indicate a 1:3 staff to client ratio at all times. Staff interviews revealed that when staff called off, other staff were asked to cover or work double shifts. If staff commented that there was an understaffing issue, it was because the same staff were being asked to work overtime, which may indicate that the facility needs more staff. Staff also noted that managers from the operations team would step in and fill a shift if need be. However, the LPA reviewed timecards from the period of Monday 4/4/2022 – Sunday 4/10/2022. Per the review, the LPA discovered there was only one non-clinical staff person working the overnight shift on 4/4/2022, one non-clinical staff person working the overnight shift on 4/8/2022, and one non-clinical staff person working the morning shift on 4/9/2022. Based on the information obtained, there is sufficient evidence to support the claim that the licensee failed to be in the required staffing ratio. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20211001081014
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2022
Section Cited
CCR
81065.5(a)(2)
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81065.5(a)(2) Day Staff-Client Ratio. Short Term Crisis Residential Programs shall have at least two direct care staff persons on duty, on the premises, any time clients are in the facility.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
Administrator will submit a comprehensive plan on what steps will be taken to ensure staffing is sufficient at all times by POC due date. Submit a completed LIC500 along with the plan by 5/9/2022.
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Based on interview and record review, the licensee did not comply with the section cited above, as the facility did not have two direct care staff on duty for all shifts, which poses an immediate health and safety risk to clients in care.

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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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5