<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:10:19 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
08/23/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230823123714
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:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan Weisbarth, Executive Director (ED)TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that resident is provided their medication(s) according to physician’s instructions.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility at 10:00 a.m. At 10:10 a.m., the LPA met with the Executive Director (ED), Susan Weisbarth and explained the reason for the visit.

During the initial visit conducted on 08/31/2023 between 9:00 a.m. and 12:30 p.m., LPA Peraldi conducted an interview with the Administrator at the time, Trevin Willis, five (5) residents, and four (4) staff. During the initial visit, the LPA also conducted a physical plant tour and obtained copies of pertinent documents. During today’s visit, between 10:10 a.m. and 2:30 p.m., the LPA conducted interviews with the ED, four (4) residents, and two (2) staff. The LPA also conducted a physical plant tour and obtained copies of pertinent documents during the time of the visit. During today’s visit, between 10:28 a.m. and 11:15 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents.
Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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 5
Control Number 29-AS-20230823123714
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: 12/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff do not ensure that resident is provided their medication(s) according to physician’s instructions. During today’s visit, between 10:28 a.m. and 11:15 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #1 (R1’s) Evening medications, Carbidopa-Levodopa 25-100 Tab, Acetaminophen 500 MG Cap, Quetiapine Fumarate 25 MG, and Memantine 10 MG Tab were not self-administered or given to the resident for 12/18/2024. Per record review and staff interview, notes or documentation from 12/18/2024 indicating that R1 refused the medication was entered on 12/19/2024. The ED stated that an in-service training will be conducted to remind staff to properly document medication refusals. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230823123714
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: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2024
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Within 24 hours, the ED will notify the LPA when medication training will be completed. Administrator stated that training for all medication staff will be completed and submit documentation to CCL by 12/31/2024.
8
9
10
11
12
13
14
Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents 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: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/23/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230823123714

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: DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan Weisbarth, Executive Director (ED)TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that residents have an operable call button (pendant).
Staff do not respond to requests for assistance in a timely manner.
Staff do not ensure that resident’s medication(s) are ordered in a timely manner.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility at 10:00 a.m. At 10:10 a.m., the LPA met with the Executive Director (ED), Susan Weisbarth and explained the reason for the visit.

During the initial visit conducted on 08/31/2023 between 9:00 a.m. and 12:30 p.m., LPA Peraldi conducted an interview with the Administrator at the time, Trevin Willis, five (5) residents, and four (4) staff. During the initial visit, the LPA also conducted a physical plant tour and obtained copies of pertinent documents. During today’s visit, between 10:10 a.m. and 2:30 p.m., the LPA conducted interview with the ED, four (4) residents, and two (2) staff. The LPA also conducted a physical plant tour and obtained copies of pertinent documents during the time of the visit. During today’s visit, between 10:28 a.m. and 11:15 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents.
Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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 5
Control Number 29-AS-20230823123714
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: 12/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff do not ensure that residents have an operable call button (pendant). Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed that there are no issues with their call buttons. On 12/19/2024, the ED explained that the resident rooms now have a movement censor and the majority of residents have a pendant. The ED explained that staff periodically check if the pendants are functional. During the visit on 08/31/2023 and 12/19/2024, the LPA tested a random sample of residents’ pendants and observed them functioning properly. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff do not respond to requests for assistance in a timely manner. It was alleged that it takes up to two (2) hours for staff to respond to request for assistance. Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed that staff respond to their request for assistance within 5-10 minutes. Resident interviews did not reveal any concerns regarding the staff response time. Interview with the ED conducted on 12/19/2024, revealed that staff aim to respond to request for assistance within 5 minutes. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff do not ensure that resident’s medication(s) are ordered in a timely manner. Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed no concerns regarding staff ordering their medications. Staff interviews conducted 08/31/2023 and 12/19/2024 revealed that medications get ordered 7-10 days prior to the current medication cycle ending. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5