Inspection Reports for
The Preserve at Woodland Hills Assisted Living & Memory Care

The complaint was unsubstantiated. Allegations included staff preventing a resident from receiving gifts and neglect leading to pressure ulcers. Investigations included interviews with staff, resident, and witnesses, review of delivery logs, photographic evidence, and medical records. Both allegations were deemed unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate the allegations. Interviews, record reviews, and observations confirmed that the resident received gifts and that pressure injuries did not develop under facility care. No deficiencies were cited.

No immediate health or safety concerns were observed during the visit. However, a deficiency was cited for failure to notify the Department, State Long-Term Care Ombudsman, residents, and their representatives in writing within two business days of the facility's default, which posed a potential health and safety risk. A civil penalty was assessed for this violation.

The visit was complaint-related, investigating three self-reported incidents including alleged resident abuse, medication errors, and elopement. The medication error was substantiated and cited as a deficiency with a civil penalty assessed.

The investigation found incidents including a staff member pushing a resident onto a toilet causing it to break, a medication administration error where a resident was given another resident's medications, and a resident leaving the facility unassisted through a back door. The facility took corrective actions including suspending involved staff, conducting staff training, and increasing supervision and safety measures.

The facility was found to be in compliance with all reviewed areas including staff records, infection control practices, emergency disaster planning, and fire safety systems. No deficiencies were cited during this inspection.

The facility was found to have multiple Type A deficiencies including improper water temperature in resident sinks, lack of call systems in resident rooms, residents having access to restricted items, and staff response times to resident calls being inadequate. Medication storage and resident records were found to be in compliance. The facility was otherwise clean and well-maintained with no immediate hazards observed.

The visit was complaint-related, investigating a self-reported incident where a medication error occurred. The complaint was substantiated with a deficiency cited and a civil penalty assessed.

The investigation found that Staff #1 left Resident #1's Benzonatate medication unattended, which Resident #2 self-administered by mistake. Resident #2 was monitored with no significant changes noted. Staff received one-on-one training and a corrective action form was issued. A civil penalty of $250 was assessed due to a repeat violation.

The complaint was substantiated based on the investigation of the incident where Resident #1 did not receive the prescribed Lorazepam dose. Staff #1 was trained and subsequently left the facility.

The investigation found that Staff #1 failed to administer Resident #1's Lorazepam medication as prescribed, posing a potential health and safety risk. Staff #1 received one-on-one training and no longer works at the facility. The facility plans to conduct vendored medication training and audit medications.

During the visit, a health and safety check was conducted with no concerns observed. The facility has sufficient beds, hygiene supplies, linens, food supplies, and staffing to accommodate both existing and relocated residents. All relocated residents have designated rooms with ensuite bathrooms, and families have been notified.

The visit was complaint-related, investigating two incidents of resident elopement. The complaint was substantiated as the facility failed to provide adequate supervision and care, resulting in elopements and safety risks.

The investigation found that two residents eloped from the facility unassisted through the same back egress door, with one resident sustaining a fall and requiring hospital transport. Facility staff failed to provide necessary care and supervision, allowing the elopements, which posed an immediate health and safety risk. The delayed egress door and alarm system were tested and found functioning during the visit.

The Licensing Program Analyst conducted interviews and a file review related to the incident report. An exit interview was conducted and the report was issued. Additional reports may follow if warranted.

The complaint investigation involved two incidents: one where two staff members were witnessed slapping a resident, and another where staff took and shared a selfie exposing a resident. Staff involved were placed on leave and families notified.

The investigation revealed reports of two staff members slapping a resident and staff taking a selfie exposing a resident in a bathroom. Staff involved were placed on leave pending further investigation by company HR. Further investigation by the Department is needed before issuing a final licensing report.

The inspection included review of resident files and medication storage. All resident files reviewed were complete, medications were properly labeled and stored, and no deficiencies were observed during the inspection.

The facility was generally found to be in compliance with health and safety standards, including clean and well-maintained common areas, kitchen, bedrooms, bathrooms, and outdoor spaces. However, deficiencies were cited related to staff training requirements, with some staff lacking the required initial and annual training hours.

The facility had not issued a refund as required by a previous complaint visit and POC. The refund check was issued late and for an incorrect amount, with an additional $561.25 owed. A civil penalty of $900 was issued during this visit.

The complaint alleged that following Resident #1's death and removal of personal belongings, no refund was issued to the resident's family/estate as required by the Admission Agreement. The allegation was substantiated based on interviews and record review.

The investigation substantiated that the facility failed to issue a refund to the resident's estate within 15 days after the removal of personal belongings as required by the Admission Agreement. The resident's account showed a carried over credit that was owed to the estate, and despite a refund request made by the Administrator, the refund had not been issued as of the visit date.

The complaint alleged that staff failed to report an incident of sexual assault involving resident #1. The investigation confirmed that the former Administrator was aware of the alleged sexual assault but did not report it to Community Care Licensing as required. The sexual assault allegation itself was unsubstantiated after interviews and review of evidence.

The investigation substantiated that staff failed to report an alleged sexual assault incident in a timely manner, violating mandated reporting requirements. However, the allegation that two staff sexually assaulted a resident was unsubstantiated due to insufficient evidence.

The visit was triggered by two self-reported incidents of suspected dependent adult/elder abuse. The substantiation status is not stated.

No immediate health and safety concerns were observed during the inspection. Further investigation is required and additional reports may follow if warranted.

The complaint was substantiated. The allegation was that the facility failed to conform with fire safety regulations due to a locked door without delayed egress. The investigation confirmed this deficiency.

The investigation found that a glass door separating the residents' dining room from the main entry lobby was locked and did not have delayed egress as required by fire safety regulations. The Los Angeles Fire Department had informed the facility that the door was not in compliance. The facility was put on notice to correct this deficiency.

The facility was toured including common areas, resident rooms, kitchen, and outside areas. All areas appeared clean, well-maintained, and in good repair with no deficiencies noted at the time of the visit. The facility had adequate supplies including PPE and food, and safety equipment was properly serviced and operable.

The complaint alleged that staff handled a resident roughly and that the resident sustained a fall while in care. The allegations were deemed unsubstantiated based on interviews, medical reports, and observations.

The investigation found insufficient evidence to substantiate the allegations. Staff were placed on administrative leave pending an internal investigation, and a skin assessment showed bruising was due to the resident bumping into objects. Interviews with staff and the resident's family supported that the resident was not abused or mistreated. Further training on elder abuse, mandated reporting, and dementia behavior interventions was recommended.

The complaint investigation was unsubstantiated. Allegations included staff neglecting a resident by leaving them unattended in soiled clothing and failing to meet care needs. Interviews, observations, and record reviews confirmed regular staff checks and care provision. The resident's incontinence was linked to prescribed medications. No evidence supported the claims of neglect.

The investigation found insufficient evidence to substantiate the allegations of staff neglect, leaving the resident unattended in soiled clothing, or failure to meet the resident's needs. Staff regularly checked on the resident, who had incontinence issues related to medication, and care was provided accordingly. All allegations were deemed unsubstantiated.

The facility was found to be generally in compliance with health and safety regulations, infection control practices were adequate, and the environment was clean and well maintained. However, a deficiency was noted regarding incomplete documentation of centrally stored medications for one resident.

The complaint was received on 2022-04-11 alleging neglect/lack of supervision resulting in facial fractures to Resident #1, staff being reprimanded for calling 911, failure to obtain timely medical care, lack of supervisor availability, and failure to notify the authorized representative. The investigation was conducted through multiple visits and interviews, concluding with substantiation of some allegations and unsubstantiation of others.

The investigation found the allegations of neglect/lack of supervision causing facial fractures and staff being reprimanded for calling 911 to be unsubstantiated. However, the allegations that staff failed to obtain timely medical care for Resident #1, a supervisor was not available for guidance, and staff did not notify the authorized representative of the resident's injury were substantiated. A $500 immediate civil penalty was assessed.

The complaint investigation was substantiated. Allegations included multiple injuries to a resident, insufficient staffing, inadequate feeding and hydration, inadequate staff training, and failure to reposition a resident. Evidence included hospital and home health records, staff interviews, file reviews, and medication audits.

The investigation substantiated all allegations, finding that Resident #1 sustained multiple pressure injuries while in care, the facility had insufficient staffing to meet resident needs, staff failed to ensure adequate feeding and hydration, staff were inadequately trained, and staff failed to reposition the resident contributing to pressure injuries. Immediate civil penalties were assessed and plans of correction were required.

The complaint investigation was substantiated. Allegations included residents' rooms not being cleaned regularly and toilet paper supplies not being replenished regularly. Observations and staff interviews confirmed these issues.

The investigation substantiated both allegations. Four out of 20 bedrooms were found unclean with debris and dried urine residue, and four out of 20 bathrooms lacked toilet paper in the dispensers. Staff interviews revealed unclear responsibilities for cleaning and replenishing supplies, contributing to the deficiencies.

The complaint investigation was substantiated. Allegations included multiple falls by a resident, delayed staff response to pendants, malfunctioning pendant system, and inadequate cleaning of residents' rooms. The investigation included interviews, observations, and record reviews confirming these issues.

The investigation substantiated all allegations: a resident sustained multiple falls due to delayed staff response; staff response to pendants was not timely due to insufficient staffing; the facility pendant system was sometimes nonfunctional; and residents' rooms were not cleaned regularly due to lack of housekeeping staff.

The complaint was substantiated. Allegations included failure to assist a resident with medication self-administration and incomplete files. Evidence included medication administration records showing missed dosages and incomplete staff files lacking valid certifications and health screenings.

The investigation substantiated that staff failed to assist Resident #1 with self-administration of medications due to missing medications and staff turnover. Additionally, staff and resident files were found to be incomplete, with missing CPR certifications, job applications, and health screenings for some staff members.

The complaint alleged that facility staff failed to supervise a resident, resulting in the resident eloping from the facility on two occasions (12/31/2021 and 2/23/2022). The investigation substantiated the allegation based on interviews and observations.

The investigation substantiated that staff failed to properly supervise resident R1, who eloped twice from the facility due to delayed egress doors being inoperable and staff not responding promptly to door alarms. The facility took corrective actions including fixing the door, installing cameras and alarms, and conducting elopement training and drills.

The visit was complaint-related based on complaint control #29-AS-20220103170508. The report does not explicitly state substantiation status.

The licensing program analyst observed accessible cleaning supplies under the kitchenette sink and accessible alcoholic beverage bottles in the kitchenette mini fridge in the resident dining area, which violated regulations requiring these items to be inaccessible to residents with dementia.

The visit was triggered by a complaint investigation under control #29-AS-20211203112208. Deficiencies were substantiated as noted in the report.

The facility was found to have multiple deficiencies including failure to have the required Residential Care Facility for the Elderly Complaint Poster, accessible wine in the Discovery Room, accessible gardening tools and planting soil in the outdoor courtyard, and a staff member (S1) working without appropriate criminal record clearance after separation from the community.

The facility was toured and found to be adequately equipped and furnished with appropriate infection control measures, safety equipment, and emergency preparedness. The facility is cleared for 60 non-ambulatory residents, including 10 bedridden residents, with adequate rooms, bathrooms, and safety features.

The administrator demonstrated understanding of licensing requirements including facility operation, admission policies, staffing, restrictive health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.

The administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness during the COMP II telephone interview.