565850150-9-16-2024-29-AS-KHEN-D9GVHS-20240926162737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850150
Report Date: 09/16/2024
Date Signed: 09/16/2024 05:07:48 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2024 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240604121259

FACILITY NAME:	VARENITA OF WESTLAKE		FACILITY NUMBER:	565850150
ADMINISTRATOR:	VEJAR, MERI		FACILITY TYPE:	740
ADDRESS:	95 DUSENBERG DRIVE		TELEPHONE:	(805) 413-3300
CITY:	WESTLAKE	STATE: CA	ZIP CODE:	91362
CAPACITY:	115	CENSUS: 90	DATE:	09/16/2024
		UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Mehrnosh (Mimi) Ghorbankhani, Wellness Manager		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.
Staff hit resident with unknown object.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kelly Dulek and Angela Barutyan conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPAs arrived at the facility at 09:57AM and met with Wellness Manager Mehrnosh (Mimi) Ghorbankhani. LPAs were informed that Executive Director and Administrator are both unavailable for today’s visit. Entrance interview conducted.

During an initial visit conducted on 06/13/2024, LPA Dulek interviewed ED at 09:55AM, toured the facility's memory care unit at 10:20AM, interviewed staff from 10:34AM to 01:30PM and again at 02:31PM and 03:09PM, interviewed Resident #1 (R1) at 02:55PM and LPA obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed all documents and conducted additional interviews. The following was then determined:

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240604121259

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: VARENITA OF WESTLAKE	FACILITY NUMBER: 565850150
	VISIT DATE: 09/16/2024

NARRATIVE

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The complaint alleges that Staff #1 (S1) was rough with Resident #1 (R1) and that S1 hit R1 with an unknown object while putting R1 to bed. LPA interviewed staff and R1, as well as R1’s family member related to the allegation and reviewed facility documents. Staff interview revealed that on the date of the alleged incident, R1 was having a rough night. R1 was agitated and was hitting the facility staff, including S1. R1 also reported to the police on the night of the incident that R1 had hit S1 in the stomach. R1 showed the police an injury which was reportedly caused by S1 that night, however police noted the injury “appeared to be a scab that was scraped off from a pre-existing injury.” Resident observations indicate that R1 had a fall on 04/16/2024, which resulted in a skin tear to R1’s left leg and small scrape to R1's right leg. Staff notes continue to mention the skin tear somewhat regularly and on 05/24/2024, the skin tear is referred to as “old skin tear” on R1’s right leg. The alleged incident occurred on 06/02/2024 and police noted the injury appeared to be an old picked off scab. LPA observed R1’s left leg during the initial visit and took photographs of the injury, which was scabbed over at that time. Physician’s report reviewed indicates R1 has a diagnosis of Mild Cognitive Impairment. LPA interviewed R1, who initially told LPA that an injury to their leg was caused while R1 was on a boat when the mast hit them in the leg. Later in the interview, R1 indicated the injury was caused by S1 hitting them with a stick, resulting in a cracked kneecap. The injury was noted to be on R1’s left lower leg, not R1’s kneecap. LPA interviewed R1’s family member related to the incident, who stated they were unsure if “it’s happened, imagined, or if [R1] dreamed it.” Staff and R1’s family member stated that R1 has been experiencing confusion and sundowning recently. LPA requested a copy of a police report from the night of the incident, however, the police did not make a written report. Based on interview and record review, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred, therefore, the allegations “Staff handled resident in a rough manner” and “Staff hit resident with unknown object” are deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC9099 (FAS) - (06/04)

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