195850091-9-4-2024-29-AS-KHEN-D9M239-20240930170157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 09/04/2024
Date Signed: 09/04/2024 04:38:54 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
08/23/2024 and conducted by Evaluator Angela Barutyan

COMPLAINT CONTROL NUMBER: 29-AS-20240823102422

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	MICHAEL OWENS		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 35	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Trevin Willis		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff violated resident’s personal rights.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 09:38AM. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit.
During today's visit, LPAs reviewed records, conducted interviews, conducted a brief physical plant tour at 10:56AM, conducted a medication review at 12:15PM, and obtained copies of pertinent documents. During the initial complaint visit which took place on 08/29/2024, LPA Barutyan spoke with ED, reviewed and obtained copies of pertinent documents, reviewed staff personnel and resident files, conducted a brief physical plant tour, and interviewed two (2) staff and four (4) responsible parties of residents. On 08/21/2024, LPA Barutyan conducted a Case Management – Incident visit to investigate two (2) incidents, of which one (1) relates to the complaint, that were self-reported to the Department. During the Case Management visit, LPA Barutyan conducted interviews with the ED and three (3) staff members, reviewed files, and obtained copies of pertinent documents relevant to the investigation. Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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-20240823102422

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: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 09/04/2024

NARRATIVE

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It was reported that staff violated a resident’s personal rights by taking a photograph of a resident in the bathroom. The Department received a self-reported incident report on 08/20/2024 stating that on an unknown date, Staff 1 (S1) and Staff 2 (S2) took a selfie in front of Resident 1 (R1) who was on the toilet in their personal bathroom and exposed in the picture. Staff members then shared the picture among their personal circles. Staff 3 (S3) reported the incident to ED Willis on 08/20/2024. Interviews conducted on 08/21/2024, 08/29/2024, and 09/04/2024 revealed that staff members S1, S2, and S3 involved in the incident have been suspended and are in the process of termination for involvement. Photo evidence from a credible witness was received. LPA Barutyan spoke with management company representative, Wendy Souders, at 10:48AM on 08/29/2024 who did not authorize to release requested documents pertinent to the investigation. LPAs spoke with Wendy Souders over the phone today, 09/04/2024, at 10AM who again did not authorize the release of requested documents. During the time of the visit around 12:30PM, the management company called ED Willis to inform him to release the requested documents to the LPAs. Based on photo evidence received from a credible witness, interviews conducted, and pertinent documents obtained, the allegation “staff violated resident’s personal rights” is deemed SUBSTANTIATED at this time.

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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240823102422

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: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/05/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	All staff members involved have been suspended and are in the process of termination. The facility has been actively hiring new staff and training on personal rights is being provided and will continue to be provided on an ongoing basis. POC is cleared.
	8 9 10 11 12 13 14	Based on interviews, record review, and evidence from a credible witness, the Licensee did not comply with the section cited above in that three (3) staff members did not respect a resident's dignity which poses an immediate personal rights risk for persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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