195850246-1-15-2025-29-AS-DPEA-DDERNV-20250130121059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850246
Report Date: 01/14/2025
Date Signed: 01/15/2025 08:46:05 AM

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
03/28/2024 and conducted by Evaluator Valeria Conway

COMPLAINT CONTROL NUMBER: 29-AS-20240328095338

FACILITY NAME:	WALNUT GARDEN III		FACILITY NUMBER:	195850246
ADMINISTRATOR:	ILLOUZ, IZHAK		FACILITY TYPE:	740
ADDRESS:	12802 COLLINS STREET		TELEPHONE:	(818) 624-1918
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	11:11 AM
MET WITH:	Izhak Illouz		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff mishandled a resident while in care - (Resident #1 (R1) sustained a fractured wrist, while under facility care)
Facility staff failed to provide timely medical care for Resident #1 (R1).

INVESTIGATION FINDINGS:

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This reports supersedes report issued on 04/03/2024.

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Conway met with Administrator Izhak Illouz and Licensee Arlene Ceballos and explained the reason for the visit.

On 03/28/2024, the Woodland Hills North Adult and Senior Care office received a complaint regarding two allegations of Lack of Care and Supervision. The complaint alleged Resident #1 (R1) sustained a fractured wrist and the facility staff failed to seek timely medical attention. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Olivia Spindola.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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 3

Control Number 29-AS-20240328095338

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: WALNUT GARDEN III	FACILITY NUMBER: 195850246
	VISIT DATE: 01/14/2025

NARRATIVE

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This reports supersedes report issued on 04/03/2024.

Continued from LIC 9099

On 04/03/2024, from 10:15 a.m. to 5:30 p.m., LPA Conway conducted an unannounced 10-day complaint visit. LPA Conway met with administrator Izhak Illouz and assistant administrator Arlene Ceballos and explained the reason for the visit. From 11:10 a.m. to 12:54 p.m., the LPA conducted a tour of the physical plant, reviewed facility files, obtained copies of pertinent documentation relevant to the investigation, and conducted interviews with facility staff, administrator, and residents.

Investigator Spindola conducted interviews on 04/24/2024, at approximately 11:00 a.m., with R1’s resident representative; on 05/14/2024, at approximately 1:00 p.m., with facility assistant administrator; on 06/04/2024, at approximately 9:00 a.m., attempted interviews with staff, left message; on 07/03/2024, from approximately 2:45 p.m. to 4:00 p.m., with administrator, staff, resident and R1’s healthcare case consultant. In addition, the investigator reviewed Encino Hospital Medical Center medical records, radiology results from Professional Imaging Network, and facility file documents related to the investigation.

According to the review of the Encino Hospital Medical Center medical records, R1 was brought in by ambulance on 03/27/2024 after a ground level fall at the facility that morning. The records noted R1 had a history of hypothyroidism, hypertension, rheumatoid arthritis, advanced dementia with psychotic feature, poor mobility, hypercoagulable state, significant dyslipidemia, and chronic low blood pressure. A deformity was noted, and an x-ray revealed left wrist fracture. R1’s resident representative chose not to proceed with surgery and preferred conservative management.

Continued on LIC 9099-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240328095338

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: WALNUT GARDEN III	FACILITY NUMBER: 195850246
	VISIT DATE: 01/14/2025

NARRATIVE

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This reports supersedes report issued on 04/03/2024.

Continued from LIC 9099-C

The Department’s investigation revealed that on 03/27/2024, at approximately 10:00 a.m., Resident #1 (R1) sustained a fall in R1’s bathroom. The facility staff attended to R1 and contacted the assistant administrator who then contacted R1’s healthcare case consultant who in turn notified R1’s resident representative, who requested R1 have x-rays taken of R1’s left wrist at the facility, instead of having R1 hospitalized, if it was not necessary. The x-ray results revealed that R1 sustained a fractured left wrist. On 03/27/2024, during the evening hours, R1’s resident representative then gave approval to the facility staff to send R1 to the hospital for medical care. R1’s resident representative did not have any concerns regarding the care R1 receives at the facility. Based on the above information, the Department did not find sufficient evidence of neglect/lack of care and supervision, therefore, the allegations “Neglect/Lack of Care and Supervision: Resident #1 (R1) sustained a fractured wrist, while under facility care” and “Neglect/Lack of Care and Supervision: Facility staff failed to provide timely medical care for Resident #1 (R1)” are deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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