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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:31:16 PM

Document Has Been Signed on 03/11/2025 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
195850091
ADMINISTRATOR/
DIRECTOR:		SUSAN WEISBARTHFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 60CENSUS: 39DATE:
03/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Susan WeisbarthTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 10:40AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 02/26/2025. Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth and staff. Entrance interview conducted.

During today's visit, LPA interviewed five (5) staff members between 10:43AM-1:01PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 11:40AM-12:36PM, conducted a brief physical plant tour at 12:40PM, and attempted interviews with two (2) residents between 03:04PM-03:06PM.

On 02/27/2025, the Department received a verbal incident report stating that on 02/26/2025, Resident #1 (R1)’s morning Lorazepam medication dose was not administered by Staff #1 (S1). The discrepancy of the missing dose was observed around 02:30PM, same day. R1’s hospice agency and responsible party were notified. R1 was monitored for changes in condition, no significant changes were noted. Health and Services Director (HSD) Tony Nunez conducted one-on-one trainings with S1 on 02/27/2025 and 03/04/2025. As of 03/06/2025, S1 no longer works at the facility. HSD stated that the facility will be auditing medications and plans to have a vendored medication training in the near future.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 03:31 PM - It Cannot Be Edited


Created By: Angela Barutyan On 03/11/2025 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2025
Section Cited
CCR
87465(h)(4)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws...
This requirement is not met as evidenced by:
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S1 no longer works at the facility. HSD stated they will schedule a vendored training soon and will submit proof to CCL of the scheduled date by 04/01/2025.
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Based on medication review and interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s Lorazepam medication was not administered by Staff #1 (S1) as prescribed, which posed 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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