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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 12/18/2024
Date Signed: 12/18/2024 06:45:09 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
12/08/2023 and conducted by Evaluator Christine Yee
COMPLAINT CONTROL NUMBER: 29-AS-20231208120748
FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:TREVIN R WILLISFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 34DATE:
12/18/2024
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Lorrain Walters, Business Office ManagerTIME COMPLETED:
06:50 PM
ALLEGATION(S):
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1. Staff did not follow the care plan established by the resident's physician
2. Staff did not inform resident's authorized person of a change to resident's care plan
3. Staff do not meet resident's toileting needs; 4. Staff do not keep the facility clean & sanitary
5. Staff did not meet the resident's hygiene needs; 6. Staff did not maintain residents laundry
7. Staff did not safeguard resident's personal items; 8. Staff do not ensure that resident is adequately fed
9. Facility window is in disrepair; 10. Staff did not keep the facility free of spiders
11. Staff did not keep the facility free of ants; 12. Staff do not prevent residents from entering another resident's room; 13. Resident's shower rod is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted another unannounced subsequent complaint visit to investigate the above allegations and met with Lorrain Walters, Business Office Manager. The reason for today's visit was provided.
On 12/11/23 Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegations. LPA met with administrator Trevin Willis and explained the reason for the visit. At 11:03 a.m. LPA discussed the complaint with the administrator. Based on the allegations the administrator was aware of the resident this complaint was regarding. While LPA was conducting a quick tour of the facility at 11:40 a.m. LPA observed housekeeping cleaning the room of resident 1 (R1). At 11:45 a.m. LPA observed R1 in the dining room. R1 appeared well groomed but anxious. At 12:30 p.m. R1 had an aggressive outburst and threw a plate of food at resident 2 (R2). Staff redirected R1 who then started yelling and wandering the halls. R1 stated they were in pain and wanted to see a doctor. Administrator

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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 4
Control Number 29-AS-20231208120748
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: 12/18/2024
NARRATIVE
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called 911. At 1:15 p.m. LPA obtained pertinent documents. This complaint requires further investigation. An LPA will return at a later date to continue this investigation. No deficiencies observed at this time. Copy of report was provided to the administrator.

On 12/17/24, Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to conduct additional investigation for the above allegations and met with Susan Weisbarth, Executive Director. The reason for today's visit was explained. On today's visit LPA Yee conducted an interview with Staff #1 at 11:28am, Staff #2 at 12:38p, Staff #3 at 1:05pm, Staff #4 at 1:33pm, Staff #5 at 2:22pm, Staff #6 at 3:20pm and toured Bedroom #102, #126 and #127 at 2:57pm. LPA Yee also obtained copies of facility documents during the visit. Per information received during the visit, it was again determined that additional investigation is needed to make findings for the above allegations. An exit interview was conducted and a copy of this report was provided.

Another unannounced subsequent complaint visit was conducted today to continue investigation of the above allegations. LPA Yee met with Lorrain Walters and Iveth Barron and the reason for today's visit was provided. LPA Yee conducted an interview with Resident #2 at 11:07am, Resident #3 at 1:33pm, Resident #4 at 12:24pm, Resident #5 at 12:35pm and Staff #6 at 1:47pm.

Per information received through interviews conducted for all the above allegations, Resident #1 was admitted to the facility with dementia. Resident #1 would refuse medications and would easily be agitated and turns very aggressive. Resident #1 would be given breakfast, lunch and dinner and would eat only about half the meal. Resident#1 is able to feed themselves but was very picky with their food and would request pancakes with syrup, ice cream with whip cream, sprinkles and syrup and used syrup on all the facility meals. Resident loves ice cream and noodles and orange chicken from Panda Express. The facility staff will order food just so that the resident will not get agitated but resident would not eat the ordered food. Resident #1 demands to be served their meal first and gets what they request so that they don't get agitated. Resident #1 would get very upset and agitated when there was no syrup or did not get what they wanted. Resident would yell and scream loudly at the staff and that they were being mean and trying to kill them. Resident would also throw cups, plates and other things, rip the shower rod down and destroy their bedroom when it was cleaned, within minutes of returning to the room. Resident #1 got so agitated that
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20231208120748
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: 12/18/2024
NARRATIVE
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at the bedroom window. Staff would attempt to re-direct the resident and would call the responsible family member for assistance via telephone or in person. As a result of this behavior, the facility asked the family to speak with the resident's doctor and obtain medications to assist with controlling the agitation. An order for CBD /THC gummies 1mg was prescribed by the physician. Resident #1 refused the CBD gummies and other medications. Multiple attempts would be made to get the resident to take the prescribed gummies and was unsuccessful. Resident #1 would be constantly agitated and confused. Resident would blame the staff for not cleaning the bedroom, refused to be assisted with changing their briefs when it was soiled or it was sopping wet or let staff wash their hands when it was observed with feces from the resident putting their hands inside their briefs or when they did not wipe themselves after having a bowel movement. Resident #1 would transfer the feces on to door handles and bedding and would often not let staff into the room to clean the mess. The wet briefs would be sopping wet and dripping urine on the floor. Resident #1 would refused to be changed and also refused to be bathed. The room would smell. They would have to bribe the resident with ice cream or a trip to San Francisco. Sometimes it worked and sometimes it didn't. Resident #1 is also particular about who gives them a bath. Resident #1 will not usually allow the 2 African American staff to bath them and prefers a male staff if they agree to a shower. Staff could clean Resident #1's room and change the bedding when the resident was out of the room. The resident's belonging would be put in order and minutes after the resident returned, Resident #1 would turn it upset down again. Resident would yell at the staff and tell staff that they do not want their room cleaned and say that someone stole their stuff when things are put away or taken to be laundered. The resident

Resident #1 was also a very messy eater. Resident #1 would throw food all over the room and get it all over their clothes. Resident #1 loved to eat their food in the bathroom. Resident #1 loved sweets and their food was always mixed with syrup and had sprinkles. Food was also all over the bathroom including the dirty plate. Per Staff, the food would be cleaned up once they were allowed into the room but until they could clean up, the syrup could attract ants and other pests. Per staff, they have not seen any ants, spiders or roaches in Resident #1's room. Per staff, they have to clean the resident's room everyday.

Per information obtained from interviews, Resident #1 was away from the facility for about 3 months. Staff were not sure where the resident went before returning to the facility. Resident #1 was observed to have lost weight upon return. Upon return, Resident #1 was still agitated and the facility staff advised the family to
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20231208120748
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: 12/18/2024
NARRATIVE
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speak with the resident's physician and obtain medications to assist with the resident's agitation. The doctor prescribed Quetiapine Fumara 25mgs, PRN, 1 tablet, every 12 hours, 2 doses in 24 hours and Quetiapine Fumara 12.50mgs at bedtime. However, for unknown reasons, the family had the doctor discontinue the medication. Resident #1 continued to de-escalate. Resident #1 believed that people were doing things to them. Resident would also not sleep at night. Per information obtained from family, they wanted to try to reduce the number of naps taken by the resident first before using prescribe medications to aide Resident #1 with sleeping during the night. However, the doctor had submitted a prescription for the sleep medication and it was filled. Once the facility received the medications, there was no reason not to dispense the medication contrary to the family's instructions. The facility is required to dispense the medication as prescribed by the doctor unless the facility or family member obtains a discontinue order from the doctor regardless of what the family wanted.

Per information provided, Resident #1 likes to leave their bedroom door unlocked. Dementia residents who wander around would enter the Resident #1's room. Resident #1 would say that they are after them or doing things to them and blame them for messing up their room. Resident #1 would imagine things.

Per information received from interviews, there is not sufficient evidence to support the allegations noted above. It may have happened or may not have happened, but there is not a preponderance of evidence to support the above the allegations, therefore the allegations are unsubstantiated at this time.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4