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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850339
Report Date: 06/13/2025
Date Signed: 06/27/2025 01:58:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/14/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20250214131031
FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR:ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 155DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rose AnguianoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Reporting requirements not met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Rose Anguiano. The reason for the visit was explained.
On 02/14/2025, Community Care Licensing Division received the above allegation. On 02/18/2025, LPA conducted the initial complaint visit and allegation above was discussed with Administrator. Between 10:30am - 11:45am, LPA reviewed and obtained copies of pertinent documents relevant to the investigation. Allegation - “Reporting requirements not met”: Information was received that facility did not report R1’s fall. During the course of investigation it was revealed that incident which involved R1 on 10/20/2024 was not reported. Three (3) staff confirmed an incident report should have been completed for the unwitnessed fall R1 sustained outside the facility on 10/20/2024. LPA confirmed the incident was not reported/received. Administrator was unable provided proof that this incident was reported.
Based on the above information gathered, there is sufficient evidence to support the allegation that a violation occurred; therefore, the allegation “Reporting requirements not met” is deemed substantiated at this time.
Exit interview conducted. A copy of the report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/14/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20250214131031

FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR:ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 155DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rose AnguianoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident falling
and sustaining a fracture.
Staff did not seek medical attention to resident.
Staff does not ensure resident's medical needs are being met.
Staff does not ensure resident is being transferred to medical appointments in a timely manner.
Staff left resident soiled.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Rose Anguiano. The reason for the visit was explained.

On 02/14/2025, Community Care Licensing Division received the above allegations. On 02/18/2025, LPA conducted the initial complaint visit and allegations above were discussed with Administrator. Between 10:30am - 11:45am, LPA reviewed and obtained copies of pertinent documents relevant to the investigation. Between 1pm-2pm, interviews were conducted with eight (8) residents. At approximately 2:30pm, LPA conducted interview with staff. Administrator was informed that the case was referred to Community Care Licensing Division Investigation Branch (IB). On 03/12/2025, Investigator Sonia Torre conducted records review, interviewed reporting party, three (3) residents and three (3) staff; on 03/25/2025 and 4/21/2025 hospital records from Southern California Hospital/UCLA West Valley Medical Center were received and reviewed; on 04/01/2025, LA City Fire Department call records were reviewed.
Following is a summary of the allegations and investigation finding: (Continue to LIC9099c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250214131031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339
VISIT DATE: 06/13/2025
NARRATIVE
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Regarding allegations “Staff did not provide adequate supervision resulting in resident falling
and sustaining a fracture and Staff did not seek medical attention to resident”: It was reported that Resident #1 (R1) is a fall risk and facility does not provide adequate supervision. On 10/21/2024, R1 was transported to dialysis appointment, and it was observed that R1 was not able to transfer from wheelchair to the chair for dialysis chair for treatment. It was revealed that R1 had a fall at the facility on 10/20/2024 and facility did not seek medical attention for R1. The clinic called an ambulance and R1 was taken to Hospital. It was determined that R1 sustained a fracture.
During the course of the investigation, records were reviewed, and interviews were conducted with residents and staff. The review of the facility records revealed R1 was independent and able to leave facility unassisted. The interview with staff revealed 911 was called on 10/20/2024 for R1 due to unwitnessed fall outside the facility. Staff further stated R1 refused medical attention when the paramedics arrived and was subsequently monitored by staff for signs of a change in condition. The review of the LA City Fire Department records confirmed that on 10/20/2024 at approximately 12:17pm, facility staff called 911 for R1 post fall incident outside the facility and R1 refused medical attention. Staff reported that R1 was monitored and complained of pain during the night but refused medical attention. On the morning of 10/21/2024, R1 went to scheduled dialysis appointment. At the appointment R1 was unable to transfer self onto treatment chair at the clinic and disclosed fall incident. Staff from the dialysis clinic called 911. R1 was transferred to the hospital due to complaint of right hip/leg pain from the mechanical fall R1 sustained the day prior. R1 was diagnosed with a closed fracture of the right pubic ramus. The interview of facility staff and records reviewed revealed that, on 10/20/2024, 911 was called immediately after becoming aware R1 sustained an unwitnessed fall. In addition, R1 was monitored by facility staff after refusing medical attention from paramedics, and staff did not observe a change in condition the following morning as R1 was still able to transfer (unassisted) onto wheelchair. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture and Staff did not seek medical attention to resident” is deemed UNSUBSTANTIATED at this time.

Regarding Allegation “Staff does not ensure resident's medical needs are being met”: It was reported that R1 requires maximum assistance in transferring and assistant device to transfer resident from wheelchair to clinic chair for treatment session for dialysis. Interview conducted with staff and records reviewed revealed that R1 had a mechanical fall and therefore had difficulty in transferring. R1 was hospitalized and returned from the hospital on 01/01/2025 with no changes. R1’s service plan was updated on 01/06/2025.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20250214131031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339
VISIT DATE: 06/13/2025
NARRATIVE
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R1’s diagnosis included congestive heart failure, gastroesophageal reflux disease; coronary artery disease, renal failure and hypothyroidism. R1 is non-ambulatory wheelchair dependent who was able to perform all ADLs independently except for showers. R1 wore a prosthesis on right leg and had bladder impairment. R1 was noted as being able to respond to verbal commands, follow instructions, manage own incontinent care needs, able to make decisions and leave facility unassisted. According to staff R1’s medical needs are met. R1 expressed being satisfied with the facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff does not ensure resident's medical needs are being met” is deemed UNSUBSTANTIATED at this time.

Regarding allegation “Staff does not ensure resident is being transferred to medical appointments in a timely manner”: It was reported that R1’s dialysis schedule is Monday, Wednesday and Friday from 7:30am-10:45am. It is alleged that R1 has been late multiple times to the appointments and therefore R1 receives partial treatment. Staff interviews and records reviewed revealed that R1 was late to a couple appointments due to the transportation company running late. Facility staff made changes and arrangement was made with a different transportation company. R1 confirmed the change and expressed that they are satisfied with accommodations made by facility staff in regard to the scheduling and meeting transportation needs. Random residents interviewed did not report any issues or concerns with transportation arrangements made by facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff does not ensure resident is being transferred to medical appointments in a timely manner” is deemed UNSUBSTANTIATED at this time.

Regarding allegation “Staff left resident soiled”: It was reported that R1 was left in soiled clothing and sent out to scheduled medical appointment. Staff interviews and records reviewed revealed that R1 is able to meet own toileting needs and if need staff assist. If R1 requires any assistance with ADLs R1 would alert staff for assistance. Staff reported the for the most part R1 is still able to toilet self. R1 confirmed being independent and able to handle own ADLs. According to staff R1 leaves the facility for scheduled medical appointments in dry clean clothing. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff left resident soiled” is deemed UNSUBSTANTIATED at this time.
Exit interview conducted. Copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250214131031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2025
Section Cited
CCR
87211(a)(1)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of..
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Administrator stated that staff are reminded of the reporting requirements and moving forward all incidents will be reported timely.
Administrator agreed to provide a self-certification letter to CCL by POC due date.
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the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5