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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610022
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:29:50 PM

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
11/08/2024 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20241108152932
FACILITY NAME:APPLETON HOMESFACILITY NUMBER:
567610022
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:1149 APPLETON RDTELEPHONE:
(747) 237-0417
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
03/13/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Myline OlivasTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are not properly supervising residents who may be a fall risk
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 09:56 AM. LPA met with facility staff who contacted the Administrator Myline Olivas the reason for the visit was explained and entrance interview was conducted. The Administrator arrived to the facility at 11:05 AM.

During the initial complaint visit on 11/12/2024 LPA Brian Balisi at approximately 1pm, conducted physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. During today’s visit between 10:00 AM and 11:15 AM LPA Byrne conducted a physical plant tour, interviewed the facility Administrator, conducted a file review for one (1) resident, and collected copies of pertinent documentation.

Continued on LIC-9099C.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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 3
Control Number 29-AS-20241108152932
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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 03/13/2025
NARRATIVE
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The allegation of “Staff are not properly supervising residents who may be a fall risk” alleges that the facility did not provide appropriate supervision and safety measures for resident #1 (R1) which resulted in R1 being hospitalized after experiencing a fall at the facility. LPA observed the resident file for R1. LPA observed the file to contain an LIC 625 Appraisal Needs and Services Plan, a Care Center Discharge Summary, and a Home Health Certification and Plan of Care that indicated R1 had a history of and was at risk for falls. During the initial 11/12/2024 visit LPA Balisi interviewed the Administrator who stated that R1 had bedrails previously equipped on their bed. The Administrator stated that due to them not having an order for bed rails and due to recent visits from licensing they were afraid of getting a citation, so the facility removed the bedrails. The Administrator stated that the bedrails were originally installed at the request of the family, but they were removed pending an order from R1’s home health agency. During today’s visit LPA Byrne interviewed the Administrator. The Administrator stated they were unaware that R1 was a fall risk before they arrived to the facility. The Administrator stated that upon identifying R1 as a fall risk they would place a protective mat on the floor alongside R1’s bed at night to mitigate the fall risk but no additional safety measures were put in place during the day. The Administrator estimated that the approximate time from the home health nurse leaving to when facility staff found R1 was 5-10 minutes. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff are not properly supervising residents who may be a fall risk” Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22 regulations and/or the Health and Safety Code the following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241108152932
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: APPLETON HOMES
FACILITY NUMBER: 567610022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2025
Section Cited
HSC
1569.312(a)
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§1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision...
This requirement is not met as evidenced by:
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Licensee will submit their plan on how they will minimize the danger for future fall risk clients, and a statement of understanding confirming that they understand the importance of providing appropriate accomidations and supervision to at risk clients. Licensee will submit POC no later than due date.
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Based on interview and file review the licensee did not comply with the section cited above as R1 suffered a fall at the facility and no safety measures were in place to minimize the risk of falls during the timeframe R1 fell which poses a potential health and safety risk to clients 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: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
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