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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850370
Report Date: 04/10/2024
Date Signed: 04/11/2024 07:14:07 AM

Substantiated


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
02/27/2024 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20240227154958
FACILITY NAME:COLONY OF THOUSAND OAKS AT SIDLEE WEST INCFACILITY NUMBER:
565850370
ADMINISTRATOR:AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:171 WEST SIDLEE STREETTELEPHONE:
(805) 496-4541
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rashita AggarwalTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are restricting a resident's visits with their family.
INVESTIGATION FINDINGS:
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On Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to deliver the findings for the allegation listed above. The LPA met with the Licensee Rashita Aggarwal and Administrator Connie Roush and explained the reason for the visit.

On 03/04/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day unannounced visit to investigate the allegation listed above. The LPA met with the Administrator Connie Roush and explained the reason for the visit. During today’s visit, the LPA, interviewed the Administrator at 11:00 a.m. and requested records pertinent to the investigation at 11:15 a.m.

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

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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-20240227154958
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: COLONY OF THOUSAND OAKS AT SIDLEE WEST INC
FACILITY NUMBER: 565850370
VISIT DATE: 04/10/2024
NARRATIVE
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Staff are restricting a resident's visits with their family.

On the allegation of staff are restricting a resident’s (R1) visit with their family; the Reporting Party’s (RP) concern is that the staff violated the personal rights of the resident by not allowing the family members to visit with R1 privately. To investigate the allegation, the LPA reviewed records presented by the facility administrator pertaining to R1, and interviewed the Conservator on 03/07/2024, and the Case Worker on 03/07/2024. The interview with the administrator revealed that the Conservator had instructed the facility staff via telephone communication that R1 was allowed to have visitations from family members, however, only when the case worker was present. Furthermore, the administrator presented to the LPA a hand- written note created by the administrator, noting the statement of restricting visitations made by the Conservator with date and time of the telephone call. No additional documentation on the restriction was presented. The LPA reviewed the conservatorship court documents; and found that the court order does not reflect restrictions placed on the family visitations.

Based on the information obtained through interviews and record review, there is sufficient evidence to support the allegation that staff violated the personal rights of the resident by not allowing the family members to visit with R1 privately. Therefore, the allegation that staff are restricting a resident's visits with their family, is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).



Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240227154958
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: COLONY OF THOUSAND OAKS AT SIDLEE WEST INC
FACILITY NUMBER: 565850370
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
87468.1(a)(11)
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87468.1-Personal Rights (a)Residents in all residential... elderly shall have all of the following personal rights. (11) To have their visitors... permitted to visit privately during reasonable hours and without prior notice... This was not met by evidence:
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POC: Administrator will submit a Statement of Understanding detailing the importance of Regulation 87468.1(a)(11) and submit by 04/12/2024.
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Based on observation, the administrator did not comply with the section cited above by stating that restrictions were place on visitations and were allowed by the facility administrator, which poses an immediate 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
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