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

The visit was an unannounced case management - incident investigation regarding three self-reported incidents that occurred on 09/11/2025 and an unknown date approximately two months prior.

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 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 inspection was an unannounced Case Management - Annual Continuation visit to evaluate compliance with licensing requirements, continuing from a prior inspection that began on 2025-07-25.

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 inspection was an unannounced complaint investigation conducted in response to allegations that staff were not allowing a resident to have visitors or phone calls.

The investigation found no sufficient evidence to substantiate the allegations. Interviews with the resident, responsible party, staff, and visitors, as well as record reviews and wellness checks, indicated that residents have the right to receive visitors and phone calls and that the resident in question declined calls on their own accord.

The complaint alleged that staff were preventing Resident #1 from receiving phone calls or visitors based on the responsible party's request rather than the resident's decision. The investigation included interviews with the resident, responsible party, staff, and visitors, review of documentation, and wellness checks. The allegations were deemed unsubstantiated due to insufficient evidence.

The inspection was a required unannounced one-year visit to evaluate compliance with licensing regulations and ensure health and safety standards at the facility.

The facility was found to have several deficiencies including improper water temperature in resident sinks, lack of call systems in resident rooms and bathrooms, 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 generally clean and well-maintained but had immediate health and safety risks due to the cited deficiencies.

An unannounced complaint investigation was conducted due to an allegation that staff do not ensure a facility door is safe for the residents while in care.

The investigation found no evidence to substantiate the allegation. Observations included a surveillance camera installation and caution signs on the door. There were no regulatory requirements for such safety features, and no evidence of lack of supervision was found. The allegation was deemed unsubstantiated.

The allegation was that staff do not ensure a facility door is safe for residents. The complaint was unsubstantiated due to lack of evidence and no regulatory requirement for windows or cameras on doors. Previous related complaint visits and interviews were referenced.

The visit was conducted as a complaint investigation following an allegation that the facility admitted residents without obtaining documentation of a medical assessment prior to acceptance.

The investigation found that all reviewed resident files contained the required medical assessments, preplacement appraisals, and admission agreements. Staff interviews confirmed knowledge of admission procedures. The allegation was deemed unsubstantiated due to insufficient evidence to prove the violation occurred.

The complaint alleged that the facility admitted Resident #1 on 05/13/2025 and Resident #2 two to three months prior without medical assessments. After review of records and interviews, the allegation was unsubstantiated.

The visit was an unannounced case management incident investigation regarding a self-reported medication error incident that occurred on 2025-04-17.

The investigation found that a staff member left Resident #1's medication unattended, which Resident #2 self-administered by mistake. No significant adverse effects were noted, but a deficiency was cited for improper medication storage and handling, and a civil penalty of $250 was assessed due to a repeat violation.

The visit was triggered by a self-reported incident on 2025-04-17 involving medication being left unattended and mistakenly self-administered by another resident. The complaint was substantiated with a deficiency cited and corrective actions taken.

An unannounced complaint investigation was conducted following allegations that staff handled residents in a rough manner and yelled at residents in care.

The investigation found no sufficient evidence to substantiate the allegations. Interviews with residents and staff, record reviews, and observations indicated that the allegations were unsubstantiated at this time.

The complaint alleged that Staff #1 restrained and pushed Resident #1 and yelled at Resident #2. Interviews with residents and staff, review of training and physician reports, and observations did not corroborate these allegations. The allegations were deemed unsubstantiated.

The visit was an unannounced case management - incident investigation regarding a self-reported incident on 02/26/2025 where a resident's morning Lorazepam medication dose was not administered.

The investigation found that Staff #1 failed to administer Resident #1's prescribed Lorazepam medication, posing a potential health and safety risk. Staff #1 received one-on-one training and subsequently left the facility. The facility plans to audit medications and provide vendor medication training.

The visit was triggered by a verbal incident report received on 02/27/2025 about a missing medication dose on 02/26/2025. Resident #1 was monitored with no significant changes noted. Staff #1 was trained and no longer works at the facility as of 03/06/2025.

An unannounced complaint investigation was conducted following allegations that staff negligence caused injury to a resident and that a facility door posed a safety concern for residents.

The investigation found insufficient evidence to substantiate the allegations of staff negligence causing injury and safety concerns related to the facility door. The resident had minor injuries, and the facility had taken steps to minimize risk, including signage and staff reminders.

The complaint alleged that on 02/22/2025, a resident was hit by a facility door opened by staff, resulting in bruising and a laceration. The investigation included interviews, document review, and observations. The allegations were deemed unsubstantiated due to lack of sufficient evidence.

An unannounced complaint investigation was conducted due to an allegation that staff retained a resident without proper admission procedures.

The investigation substantiated that Resident #1 was admitted without an admission agreement, pre-placement appraisal, or care plan, residing at the facility for five days without a contract. Current administration is knowledgeable and compliant with admission procedures.

The complaint alleged that staff retained a resident without proper admission procedures. The allegation was substantiated based on record review and interviews. The previous Executive Director admitted Resident #1 without proper admission documentation. Current administration has corrected the issue.

Unannounced case management visit regarding a self-reported incident on the relocation of 20 residents from Bentley Suites to Preserve at Woodland Hills due to mandatory evacuation orders from Fire Advisory.

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 an unannounced case management incident investigation regarding two self-reported elopement incidents involving residents that occurred on 12/05/2024 and 12/22/2024.

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 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 inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure residents received medications according to physician instructions, among other complaints.

The investigation substantiated that staff failed to properly assist a resident with self-administered medications per physician's orders, posing an immediate health and safety risk. Other allegations regarding operable call buttons, timely staff response, and timely medication ordering were unsubstantiated.

The complaint investigation was substantiated regarding medication administration failures. Other allegations about call buttons, staff response times, and medication ordering were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations regarding resident care, facility cleanliness, and safety concerns at The Preserve at Woodland Hills.

After multiple unannounced visits and interviews with staff, residents, and administrators, the investigation found insufficient evidence to substantiate the allegations. Resident #1 exhibited behaviors related to dementia, including agitation and refusal of care, but no deficiencies were observed at the time of the visits.

The complaint included allegations that staff did not follow the resident's care plan, failed to inform authorized persons of care changes, did not meet toileting and hygiene needs, failed to maintain laundry and safeguard personal items, did not ensure adequate feeding, and that the facility was unclean and in disrepair. The investigation was unsubstantiated due to lack of sufficient evidence.

The visit was an unannounced complaint investigation conducted due to an allegation that the facility does not have enough staff to meet the needs of residents in care.

The investigation found insufficient evidence to support the allegation of inadequate staffing. Observations, interviews, and record reviews showed that staffing levels met regulatory requirements and no citations were issued. The allegation was deemed unsubstantiated.

The complaint alleged insufficient staffing to meet resident needs. Multiple interviews and record reviews were conducted, including observations of staff on duty and resident care. Despite concerns expressed by residents, family members, and staff, staffing records showed adequate coverage. The allegation was unsubstantiated.

An unannounced complaint investigation was conducted due to an allegation that a resident was physically abused while in care.

The investigation found insufficient evidence to corroborate the allegation of physical abuse. The resident was noted to have severe dementia and exhibited aggressive behavior during showers. No deficiencies were cited and the allegation was deemed unsubstantiated.

The complaint alleged that on 10/08/2024, Resident #1 was observed in distress and crying, claiming to have been beaten. Interviews with the complainant, responsible party, and staff indicated the resident's aggressive behavior and a small bruise unrelated to abuse. Police wellness check confirmed the resident's safety. The allegation was unsubstantiated due to insufficient evidence.

The visit was an unannounced complaint investigation conducted in response to an allegation that staff overmedicated residents in care.

The investigation included interviews, medication reviews, and record audits which found no evidence of medication errors or overmedication. The allegation was deemed unsubstantiated due to insufficient evidence.

The complaint alleged that staff overmedicated residents, specifically that medication technicians administered painkillers that were too strong. The investigation found medications were administered as prescribed and no violations were observed. The allegation was unsubstantiated.

The inspection was conducted as a follow-up on a self-reported incident involving Staff #1 placing a cloth over Resident #1's mouth after the resident attempted to bite the staff member.

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 visit was an unannounced complaint investigation triggered by an allegation that the licensee does not ensure that staff are adequately trained.

The allegation was substantiated based on record review and interviews. The facility had two pending citations from a prior annual visit for incomplete staff training, with plans of correction still pending. Evidence was provided that in-service training has been conducted since the prior visit and personnel are allotted time to complete online training. No new deficiency was cited at this time.

The complaint alleged that the licensee does not ensure that staff are adequately trained. The allegation was substantiated. The facility had two citations from a prior visit for incomplete initial and annual training, with plans of correction pending and due 09/06/2024.

An unannounced complaint investigation was conducted in response to allegations that a resident was locked in their room, staff did not provide meals in a timely manner, and staff did not meet the resident's care needs.

The investigation found insufficient evidence to substantiate the allegations. Observations and interviews confirmed that residents could exit their rooms freely, meal service was timely under the circumstances, and staff conducted regular checks on residents. Therefore, all allegations were deemed unsubstantiated.

The complaint included allegations that a resident was locked in their room, meals were delayed causing weight loss, and staff failed to meet care needs. After review of records, interviews, and observations, all allegations were found unsubstantiated due to insufficient evidence.

The visit was conducted as an unannounced case management investigation regarding two self-reported incidents involving staff misconduct and privacy violations at the facility.

The investigation found that two staff members were witnessed slapping a resident and that several staff took and shared an inappropriate selfie exposing a resident. Staff involved were placed on leave pending further investigation by company HR, and families were notified.

The visit was complaint-related based on incident reports received on 08/17/2024 and 08/20/2024. The allegations included physical abuse of a resident and violation of resident privacy. The substantiation status is not stated as further investigation is needed.

The visit was an unannounced Case Management - Annual Continuation inspection to review compliance with licensing requirements.

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 inspection was conducted as an unannounced complaint investigation following allegations that the facility admitted a resident beyond their level of care and failed to ensure the resident's diabetic needs were met.

The investigation substantiated that the facility admitted a diabetic resident who could not perform self-glucose testing and lacked a skilled professional to perform the test, resulting in the resident's blood sugar not being tested daily. The resident was moved out of the facility due to unmet diabetic care needs.

The complaint alleged that Resident #1, who is diabetic and requires twice daily finger prick blood sugar testing, was admitted despite lacking capacity to self-test and the facility lacking skilled staff to perform the test. The complaint was substantiated based on record review and staff interviews.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff handled residents in a rough manner.

The investigation found insufficient evidence to substantiate the allegation of rough handling by staff. Interviews with staff and residents did not reveal concerns, and the allegation was deemed unsubstantiated.

The complaint alleged that Staff 1 or Staff 2 handled residents roughly, causing a skin tear. Interviews with staff and residents did not corroborate the allegation. The complaint was deemed unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced required annual visit conducted to ensure the facility's compliance with Title 22 regulations and to evaluate health and safety conditions.

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 40 hours and annual 20 hours of training.

An unannounced complaint investigation was conducted due to an allegation that the facility's Executive Director/Administrator abandoned the facility without proper notice.

The investigation substantiated the allegation that the Administrator, Michael Owens, resigned without proper notice and abandoned the facility, leaving management vacancies and posing an immediate health and safety risk to residents. The management company intervened to assist, and the facility is working to fill vacancies.

The complaint alleged that the Executive Director/Administrator Michael Owens abandoned the facility without proper notice. The allegation was substantiated based on evidence including a resignation letter dated 07/22/2024 and staff interviews confirming the Administrator's absence and lack of response. The management company was notified and sent personnel to manage the facility.

An unannounced Plan of Correction (POC) visit was conducted to issue a civil penalty for a POC that had not been corrected within the required timeframe.

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 inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not adhering to a resident's Admission Agreement regarding refund issuance following the resident's death and removal of personal belongings.

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 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 visit was an unannounced complaint investigation triggered by a complaint received on 2023-08-11 regarding failure to report an incident and allegations of sexual assault of a resident by staff.

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 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 inspection was conducted as a follow-up on two self-reported Reports of Suspected Dependent Adult/Elder Abuse submitted on 12/18/2023 and 12/20/2023.

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

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

The inspection visit was an unannounced complaint investigation triggered by an allegation that the facility failed to conform with fire safety regulations.

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 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 inspection was a required annual unannounced visit to evaluate the facility's compliance with licensing regulations.

The inspection found the facility to be in good condition with no deficiencies noted at the time of the visit. Areas inspected included common areas, resident rooms, kitchen, and outside areas, all of which were clean, well-maintained, and properly supplied.

The inspection visit was an unannounced complaint investigation triggered by allegations that staff handled a resident in a rough manner and that the resident sustained a fall while in care.

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 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 inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-05-11 regarding staff neglect, leaving a resident unattended in soiled clothing, and failure to meet a resident's needs.

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 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 inspection was an unannounced required annual visit with an emphasis on infection control practices and procedures.

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 inspection was conducted due to a complaint alleging neglect/lack of supervision resulting in Resident #1 sustaining facial fractures, staff getting into trouble for calling 911, failure to obtain timely medical care, lack of supervisor availability, and failure to notify the authorized representative of resident injury.

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 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 inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-03 concerning multiple allegations including resident injuries, insufficient staffing, inadequate feeding and hydration, inadequate staff training, and failure to reposition a resident.

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 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.

An unannounced complaint investigation visit was conducted in response to allegations that residents' rooms were not being cleaned regularly and that residents' toilet paper supply was not being replenished regularly.

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 residents' rooms not being cleaned regularly and toilet paper supplies not being replenished regularly. Observations and staff interviews confirmed these issues.

The inspection was an unannounced complaint investigation visit triggered by allegations including multiple resident falls, delayed staff response to pendants, disrepair of the pendant system, and inadequate cleaning of residents' rooms.

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 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 visit was an unannounced complaint investigation triggered by allegations received on 2021-12-03 regarding staff failing to assist a resident with self-administration of medication and incomplete staff and resident files.

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 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 inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-03 regarding facility staff failing to supervise a resident, resulting in the resident eloping from the facility.

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 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 inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220103170508.

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

The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20211203112208.

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

The visit was a prelicensing inspection for a new facility application for 60 residents, including a Hospice Waiver requested for 10 residents.

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 visit was an initial licensing evaluation conducted via telephone interview with the administrator to verify identification and confirm understanding of California Code Title 22 Regulations and facility operation requirements.

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.

Initial licensing evaluation conducted via telephone interview with the administrator to verify understanding of California Code Title 22 Regulations and pre-licensing readiness.

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.

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