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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850243
Report Date: 07/16/2025
Date Signed: 07/16/2025 03:39:41 PM

Unsubstantiated


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
12/30/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20241230123842
FACILITY NAME:LAUREL HEIGHTSFACILITY NUMBER:
565850243
ADMINISTRATOR:JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:13960 PEACH HILL DRIVETELEPHONE:
(805) 292-0700
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY:112CENSUS: 72DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Johnny OrtizTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 1:20 P.M. LPA met with the Executive Director (ED), Johnny Ortiz, and explained the purpose of the visit.

On 01/08/2025, LPA Zabel Chochian conducted an initial 10-day complaint visit. During the visit, LPA Chochian completed a physical plant tour, requested and obtained copies of resident roster, staff roster and staffing schedule. LPA also met and interviewed five (5) staff members and eight (8) residents. On 04/03/2025, LPA Conway conducted a subsequent complaint visit. During this visit, a physical plant tour was conducted, along with an audit of resident medications and the centrally stored medication log. LPA Conway interviewed the ED, two (2) Med-Techs, one (1) resident, and reviewed and obtained documents pertinent to the investigation. The Reporting Party (RP) was anonymous therefore, the LPAs were unable to obtain additional information regarding the allegations.
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
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-20241230123842
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
VISIT DATE: 07/16/2025
NARRATIVE
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Continued from LIC 9099

Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined:

It was reported that “Staff are mismanaging residents’ medications”, as it was reported that the facility does not have sufficient staffing to properly care for residents and that medications were not being administered. Additionally, it was alleged that memory care residents were being left alone in their rooms to manage their own treatments. An interview with the ED confirmed that, during staff shortages, the facility relies on staffing agencies to provide temporary caregivers as needed to fill vacant positions or cover staff call outs. This is being done to ensure that staffing levels remain adequate to meet residents’ needs. Interviews with residents revealed that the facility had been experiencing challenges maintaining consistent staffing levels. Some residents expressed dissatisfaction with the frequent turnover of caregivers; however, they confirmed that their medications were being administered on time and on a daily basis. Staff interviews acknowledged ongoing staffing challenges, with some staff reporting they are occasionally required to take on additional responsibilities or work extended shifts. Despite feeling overwhelmed at times staff emphasized that resident needs are being met and medications are dispensed on time. Staff also denied leaving residents unattended during treatment times. Furthermore, staff reported that they follow physician orders regarding the administration of medications, including when medication must be crushed or dissolved. Interviews with credible witnesses, including family members, indicated that their loved ones are receiving appropriate care, and no concerns regarding medication management were reported. Additionally, LPA selected seven (7) random residents and conducted a comparison of the centrally stored medication log and medication supply in the medication room was conducted. No discrepancies were observed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations ““Staff are mismanaging residents’ medications” is deemed Unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
12/30/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20241230123842

FACILITY NAME:LAUREL HEIGHTSFACILITY NUMBER:
565850243
ADMINISTRATOR:JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:13960 PEACH HILL DRIVETELEPHONE:
(805) 292-0700
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY:112CENSUS: DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Johnny OrtizTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure facility door was not in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 1:20 P.M. LPA met with the Executive Director (ED), Johnny Ortiz, and explained the purpose of the visit.

On 01/08/2025, LPA Zabel Chochian conducted an initial 10-day complaint visit. During the visit, LPA Chochian completed a physical plant tour, requested and obtained copies of resident roster, staff roster and staffing schedule. LPA also met and interviewed five (5) staff members and eight (8) residents. On 04/03/2025, LPA Conway conducted a subsequent complaint visit. During this visit, a physical plant tour was conducted, along with an audit of resident medications and the centrally stored medication log.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
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 6
Control Number 29-AS-20241230123842
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
VISIT DATE: 07/16/2025
NARRATIVE
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Continued from LIC 9099

LPA Conway interviewed the ED, two (2) Med-Techs, one (1) resident, and reviewed and obtained documents pertinent to the investigation. The Reporting Party (RP) was anonymous therefore, the LPAs were unable to obtain additional information regarding the allegations. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined:

It was reported that “Staff did not ensure facility door was not in disrepair” as it was alleged that the front door of community was not functioning and that no corrective action had been taken to address the issue. During the course of the investigation, interviews revealed that the automatic system for the main entry double doors did not consistently engage when the ADA push plate was activated, preventing the doors from opening automatically. This malfunction was challenging for residents using wheelchairs, walkers or any mobility devices, as well as for staff and visitors to safely enter and exit the facility. An interview with the ED acknowledges that the main double doors had been experiencing issues. However, as soon as the problem was identified, a third-party vendor was contacted to assess and repair the doors. Furthermore, the ED stated that while the doors were not functioning properly, staff and front desk personnel assisted residents who requested and/or required help entering or exiting the facility. On 12/23/24, the diagnosis revealed that the transfer hinge wires were broken, and a new motor drive reaction kit had to be ordered. During this visit, a temporary adjustment was made, and the vendor recommended ordering new parts. On 12/30/24, adjustments were made to the solenoid latch, followed by additional repairs on 1/6/25 and on 1/15/25. On 2/20/2025, the vendor returned and installed a new motor drive retraction kit and replaced broken wires. After the repairs were completed, the main double doors were tested and found to be functioning properly.

Continued on LIC 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20241230123842
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
VISIT DATE: 07/16/2025
NARRATIVE
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Continued from LIC 9099-C

Documentation gathered during the investigation, including work orders and invoices, supports the information provided by the ED, however, during today’s visit, the LPA observed a sign posted on one of the main double entrance doors that read “Please use other door”, with an arrow pointing to the opposite door. The ED stated that the motor of the ADA push plate device is broken. A replacement part has been ordered, and repairs are scheduled to be completed on 07/17/2025. Between 2:05 P.M. and 3:00 P.M. LPA interviewed staff and residents, who reported that the door has been experiencing intermittent issues for several months and has remained in disrepair for the past two (2) weeks. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that main doors were malfunctioning and the automatic system was not functioning properly. Therefore, the above allegation “Staff did not ensure facility door was not in disrepair” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20241230123842
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: LAUREL HEIGHTS
FACILITY NUMBER: 565850243
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2025
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by
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ED has schedule a company to come an fix the main door. A video showing ADA push plate in operable condition shall be submitted to LPA before POC due
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Based on observations the ED did not comply with the section cited above as the main door automatic system was observed to be in disrepair which poses a potential health and safety risk to persons 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: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6