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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608283
Report Date: 05/14/2025
Date Signed: 05/14/2025 02:05:02 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
11/12/2024 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20241112154102
FACILITY NAME:HILLTOP HAVEN 2FACILITY NUMBER:
197608283
ADMINISTRATOR:ERWIN DUFFELSFACILITY TYPE:
740
ADDRESS:6531 GLORIA AVENUETELEPHONE:
(818) 474-9671
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 5DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Thomas StilesTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff are not following physician's orders.
Residents are left in soiled diapers for an extended amount of time.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegations listed above and to deliver findings. The LPA met with Administrator Thomas Stiles and Cathy Harris and explained the reason for the visit.

On 11/14/2024, LPA Urena conducted an initial visit to investigate the allegations listed above. The LPA interviewed the facility representative, staff, residents, and residents’ representatives from 11:01 a.m. to 1:45 p.m., and requested records pertinent to the investigation.

Continues on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
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 2
Control Number 29-AS-20241112154102
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: HILLTOP HAVEN 2
FACILITY NUMBER: 197608283
VISIT DATE: 05/14/2025
NARRATIVE
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Staff are not following physician's orders.
On the allegation that staff are not following doctor’s orders, it is the concern of the Reporting Pary (RP) that the staff are not repositioning residents every two hours as indicated by the resident’s (R1) physician’s orders. To investigate the allegation, the LPA interviewed staff, residents, and the RP. Per the RP, the resident’s representative visited the resident during the weekend; after four (4) hours of being at the facility, R1’s representative noticed that the staff (S1) failed to turn the resident (R1) every two hours per doctor’s orders. When the resident’s representative asked the staff on site (S1) to reposition R1, the staff stated that they could not do it (physically). Furthermore, the R1’s representative stated that S1 was the only one at the facility on the day of the visit. The LPA interviewed the residents, and two (2) out of three (3) residents stated that they do not need assistance with repositioning, one resident stated that they get assistance from staff to turn and reposition throughout the day. Residents stated that typically, the facility’s representative is at the facility on weekends along with S1. The interview with the facility’s representative revealed that they were at the facility on the day of the visit, however they admitted that they went out to do some shopping for groceries and were not gone for more than an hour. The LPA was unable to interview S1, or R1. Record review revealed that R1 resided at the facility for two weeks, was admitted to the facility with hospice services; hospice record review indicated that R1 had to be reposition every two hours.
Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed Unsubstantiated at this time.
Residents are left in soiled diapers for an extended amount of time.
On the allegation that residents are left in soiled diapers for an extended amount of time, it is the concern of the reporting party that residents get a diaper change only twice a day, once in the morning and once at night. To investigate the allegation the LPA interviewed staff and residents. The staff interviews revealed that staff check on residents every two hours day and night, but may need to change soiled diapers more often, depending on the need of the residents. Furthermore, staff stated that residents have a call button to call staff if they need to have a diaper change. The residents’ interviews revealed that they get a diaper change more often than two times a day, and/or as needed.
Based on the information obtained through residents’ and staff interviews, it is apparent that residents get a diaper change throughout the day, and as needed or requested by residents. Therefore, the allegation is deemed Unsubstantiated at this time.
No citations were issued at this time. Exit interview was conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
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