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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609856
Report Date: 06/25/2021
Date Signed: 06/25/2021 04:56:02 PM

Unsubstantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210617103414
FACILITY NAME:WESTFIELD SENIOR LIVINGFACILITY NUMBER:
197609856
ADMINISTRATOR:BALASANYAN, MARIAMFACILITY TYPE:
740
ADDRESS:7633 MASON AVETELEPHONE:
(818) 384-1134
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 4DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Anna GrigoryanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Proper safety precautions were not followed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for the visit. LPA spoke with the administrator by telephone and explained the reason for this visit.
Regarding the allegation above it is alleged that resident #1 (R1) has a medical condition that requires R1 and facility staff to follow certain safety precautions with regards to treatment for R1. During the visit a Kaiser Home Health Nurse was present and treating R1. LPA conducted an interview with the Kaiser Home Health Nurse, facility staff, R1, and the administrator. LPA reviewed R1's facility file and obtained copies of pertinent information. Information from interviews reveal that R1 was discharged back to the hospital on 6/9/21 and a home health nurse came to the facility on 6/10/21. The home health nurse who came on 6/10/21 did not properly explain the safety precautions and once another home health nurse came and explained the proper safety precautions facility staff followed the proper safety precautions related to R1. Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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