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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197690045
Report Date: 03/23/2022
Date Signed: 03/23/2022 03:38:38 PM

Document Has Been Signed on 03/23/2022 03:38 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. #250
WOODLAND HILLS, CA 91364
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: 5DATE:
03/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Blake ForbesTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20211001081014.

During today’s visit, the LPA compared the current staff schedule to the Department clearance list, and identified that three employees (Staff #1, Staff #2, Staff #3) were working at this facility either without a clearance transfer or the clearance status was set to ‘Pending’.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties assessed in the amount of $9,000 related to individuals working at this location without a criminal record transfer, clearance, and/or exemption on file. See LIC421BG.

The facility was cited for this violation on 08/03/2021 and 10/05/2021. As such, an additional civil penalty of $250 is assessed due to a repeat violation. See LIC421IM.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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Document Has Been Signed on 03/23/2022 03:38 PM - It Cannot Be Edited


Created By: Ashley Smith On 03/23/2022 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2022
Section Cited
CCR
81019(e)(1)

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81019(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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The Licensee agrees to do the following:
1. Submit appropriate paperwork the three staff and confirm that the staff are associated to the facility prior to allowing them to return to work.
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Based on record review, the Licensee did not comply with the section cited above, as there were three staff (S1, S2, S3) working whom were not associated to this facility, which poses an immediate health and safety risk to clients in care.
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Civil penalty assessed due to repeat violation.

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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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022


LIC809 (FAS) - (06/04)
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