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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850150
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:57:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
11/14/2023 and conducted by Evaluator Angela Barutyan
COMPLAINT CONTROL NUMBER: 29-AS-20231114124155
FACILITY NAME:VARENITA OF WESTLAKEFACILITY NUMBER:
565850150
ADMINISTRATOR:VEJAR, MERIFACILITY TYPE:
740
ADDRESS:95 DUSENBERG DRIVETELEPHONE:
(805) 413-3300
CITY:WESTLAKESTATE: CAZIP CODE:
91362
CAPACITY:115CENSUS: 86DATE:
12/26/2024
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Mehrnoush "Mimi" GhorbankhaniTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide a call assistance button or pendant to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegations listed above at 10:38AM. LPA met with staff and Wellness Manager (WM) Mehrnoush “Mimi” Ghorbankhani and explained the reason for the visit.

During today's visit, LPA Barutyan conducted a brief physical plant tour, interviewed three (3) staff and one (1) resident, and reviewed and obtained copies of pertinent documents. During the initial complaint visit which took place on 11/21/2023, LPA C. Yee reviewed and obtained copies of facility records and conducted interviews with Executive Director (ED) Bradley Stewart, Wellness Director (WD) Mark Brassfield, Staff #1, and Resident #1.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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 6
Control Number 29-AS-20231114124155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150
VISIT DATE: 12/26/2024
NARRATIVE
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It was alleged that staff did not provide a call assistance button or pendant to Resident #1 (R1). LPA C. Yee conducted interviews on 11/21/2023 and four (4) out of four (4) parties interviewed stated that R1 did not have a pendant for a time ranging between one (1) to two (2) days to three (3) weeks. On 10/26/2023, R1 was transferred from assisted living where majority of residents are provided call pendants, to memory care where majority of residents are not provided call pendants. R1 does not have dementia but was transferred to memory care with family’s consent because R1 had increased care needs. The memory care unit consists of twenty-eight (28) rooms, which allows memory care staff to check the residents in the memory care unit more frequently and provide higher levels of care. Per interviews conducted on 12/26/2024, residents in memory care are provided with pendants if their assessment determines that they are able to properly use one. R1’s mental capability of using the pendant did not change when moved to memory care as R1 did not have a change of mental condition. R1 was provided with a pendant after request. R1 was moved back to assisted living on 04/14/2024 after R1’s condition improved. LPA Barutyan observed a pendant with R1 on 12/26/2024. Based on interviews and record review, the allegation “staff did not provide a call assistance button or pendant to resident” is deemed SUBSTANTIATED at this time. R1 and responsible parties of R1 did not have current concerns about pendant usage or call assistance buttons as R1 is now provided with a pendant.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20231114124155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2025
Section Cited
CCR
87303(i)(1)
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87303 Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more...shall have a signal system which shall:
This requirement is not met as evidenced by:
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During the time of the visit, R1 was observed with a pendant. POC is cleared.
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Based on interviews, the licensee did not comply as R1 was without a pendant for a period of time which posed a potential health, safety, and personal rights risk to person(s) 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
11/14/2023 and conducted by Evaluator Angela Barutyan
COMPLAINT CONTROL NUMBER: 29-AS-20231114124155

FACILITY NAME:VARENITA OF WESTLAKEFACILITY NUMBER:
565850150
ADMINISTRATOR:VEJAR, MERIFACILITY TYPE:
740
ADDRESS:95 DUSENBERG DRIVETELEPHONE:
(805) 413-3300
CITY:WESTLAKESTATE: CAZIP CODE:
91362
CAPACITY:115CENSUS: 86DATE:
12/26/2024
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Mehrnoush "Mimi" GhorbankhaniTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff isolated resident in their room
Staff did not assist resident in receiving physical therapy as needed
Staff did not assist resident with hygiene needs
Staff left resident in wet briefs for extended period
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegations listed above at 10:38AM. LPA met with staff and Wellness Manager (WM) Mehrnoush “Mimi” Ghorbankhani and explained the reason for the visit.

During today's visit, LPA Barutyan conducted a brief physical plant tour, interviewed three (3) staff and one (1) resident, and reviewed and obtained copies of pertinent documents. During the initial complaint visit which took place on 11/21/2023, LPA C. Yee reviewed and obtained copies of facility records and conducted interviews with Executive Director (ED) Bradley Stewart, Wellness Director (WD) Mark Brassfield, Staff #1, and Resident #1.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20231114124155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150
VISIT DATE: 12/26/2024
NARRATIVE
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It was alleged that staff isolated resident in their room as Resident #1’s (R1) door is kept closed and locked, and R1 is unable to go outside. Interviews conducted on 11/21/2023 explained that R1 does not like to partake in activities and prefers to be in their room. LPA Barutyan interviewed R1 and responsible party of R1 who shared that R1 likes to stay in their room but has been outside a few times when offered by R1’s visitors. It was further shared that staff do not directly offer to take R1 outside, but R1 and responsible party of R1 stated that if R1 requested, staff would take R1 outside. During today’s visit on 12/26/2024, LPA observed R1’s room door open and not locked. R1 stated they did not have concerns about their ability to leave their room, they just prefer to stay in their room. Based on interviews and observation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff isolated resident in their room” is deemed UNSUBSTANTIATED at this time.

It was further alleged that staff did not assist resident in receiving physical therapy as needed. Interviews conducted expressed that R1 was not receiving physical therapy as they did not have an order for it. Record review on 11/21/2023 documented that R1 was on hospice and was receiving assistance/education on performing own activities of daily living (ADLs) and receiving assistance/education on mobility and proper passive range of motion exercises from R1’s hospice agency. No order for physical therapy for R1 was prescribed. LPA Barutyan interviewed R1’s responsible party on 12/20/2024 who did not express concerns of R1’s physical therapy needs and stated they were unaware if R1 requires need for it. Based on interviews and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff did not assist resident in receiving physical therapy as needed” is deemed UNSUBSTANTIATED at this time.

Report Continued on LIC 9099-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20231114124155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150
VISIT DATE: 12/26/2024
NARRATIVE
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Lastly, it was alleged that staff did not assist resident with hygiene needs and staff left resident in wet briefs for extended period. Interviews conducted by LPA Yee on 11/21/2023 with R1 and three (3) facility staff explained that R1 is checked at least every two (2) hours for incontinence and is showered five (5) to seven (7) days a week. R1 did not express immediate concerns about hygiene assistance when interviewed on 11/21/2023 and 12/26/2024. Responsible party of R1 stated that R1 is changed often and is provided showers any time R1 requests. Responsible party further stated that R1 is not left in soiled briefs for extended periods and that the longest period was around one (1) hour. Review of records from 11/21/2023, documents that R1’s laundry is cleaned twice a week on Mondays and Fridays, and showers are provided seven (7) days a week; four (4) days from facility staff and three (3) days from hospice staff. R1’s care plan from 11/21/2023 also documents incontinence assistance twelve (12) times daily and bathing assistance one (1) time daily. R1’s updated care plan from 12/26/2024, documents incontinence assistance three (3) times daily and bathing assistance four (4) times a week. Interviews with facility staff on 12/26/2024 elaborated that the incontinence and bathing assistance frequencies in the updated plan are the minimum provided and that additional assistance is performed as needed. Staff stated that R1 is able to use their pendant to notify when R1 needs assistance and that R1 typically gets changed four (4) to five (5) times per shift. Based on interviews and record review, the Department does not have sufficient evidence to corroborate the allegations. 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 did not assist resident with hygiene needs” and “Staff left resident in wet briefs for extended period” are deemed UNSUBSTANTIATED at this time.

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6