Inspection Reports for The Variel of Woodland Hills

The inspection visit was a Case Management - Annual Continuation visit conducted unannounced to evaluate compliance with licensing requirements and ensure health and safety standards at the facility.

The facility was toured extensively including resident rooms, bathrooms, common areas, and outdoor areas. No citations were issued. The facility was found to be in compliance with Title 22 regulations, with adequate safety measures, functional equipment, and proper emergency systems in place.

The inspection was an unannounced Case Management - Annual Continuation visit to review the facility's compliance with licensing requirements, including infection control, emergency disaster planning, and staff and resident record reviews.

The facility's infection control practices and emergency disaster plan were found adequate. However, four out of seven care staff files were missing valid first aid certification, which was cited as a deficiency posing a potential health and safety risk.

Licensing Program Analyst Emily Peraldi conducted an unannounced required annual visit to this facility to evaluate compliance with licensing requirements.

The inspection included a physical plant tour and a review of medication and medication documentation for eleven residents, which were found to be properly documented and assisted as prescribed. Medications were securely stored. The inspection was not completed due to time constraints and will be continued at a later date.

The inspection was an unannounced complaint investigation triggered by an allegation that a resident eloped without supervision while in care.

The investigation found that the resident left the memory care unit unsupervised on two occasions but did not leave the facility grounds and was found unharmed. The incidents did not meet the regulatory definition of elopement, and there was insufficient evidence to substantiate the allegation. No deficiencies were cited.

The complaint alleged that Resident #1 eloped without supervision while in care. The investigation determined the allegation was unsubstantiated as the resident did not leave the facility unsupervised and was not missing for an extended period.

The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation to issue a citation for a deficiency observed during the initial complaint investigation.

The facility was found noncompliant as two residents (R1 and R2) left the memory care unit unsupervised via elevator on multiple occasions, posing a potential health, safety, and personal rights risk. The memory care exit doors to the elevator were not supervised at all times and were not delayed egress, allowing residents to access other floors unsupervised.

The visit was triggered by Complaint Control # 29-AS-20250515120119. The complaint involved residents leaving the memory care unit unsupervised, which was substantiated by staff and responsible parties' interviews and observations.

The inspection was an unannounced complaint investigation conducted due to allegations including staff not ensuring resident's doors are in good repair, medication administration issues, inadequate supervision resulting in resident wandering, and inadequate food service.

The allegation regarding resident doors not being in good repair was substantiated with two out of three doors observed lacking functional door closers, which were repaired during the visit. Allegations related to medication administration, supervision, and food service were unsubstantiated based on record reviews, interviews, and observations.

The complaint investigation was substantiated for the allegation that staff did not ensure resident's doors were in good repair. Allegations regarding medication administration, supervision of residents to prevent wandering, and adequacy of food service were unsubstantiated.

An unannounced complaint investigation was conducted due to allegations that staff were not ensuring infection control practices and did not notify appropriate agencies of an outbreak.

The investigation found that the facility implemented multiple infection control measures including closing common areas, using PPE, and notifying families. Incident reports and notifications to the public health department were timely. There was insufficient evidence to substantiate the allegations, and no deficiencies were cited.

The complaint alleged failure to follow infection control practices and failure to notify appropriate agencies of an outbreak. The allegations were deemed unsubstantiated due to insufficient evidence despite some validity of the claims.

The inspection visit was conducted as an unannounced complaint investigation in response to an allegation that staff were not providing residents with comfortable accommodations due to heavy noises coming from the unit above certain residents' shared unit.

The investigation found no sufficient evidence to substantiate the allegation. Multiple attempts were made by the facility to address the noise concerns, including plumbing and HVAC inspections and offering to relocate residents. Interviews with residents and staff did not support the allegation, and the unit above was vacant for about three weeks during the alleged noise period.

The complaint was unsubstantiated. The allegation involved noise disturbances affecting residents' comfort. Investigations included interviews, document reviews, and inspections. No evidence was found to corroborate the complaint.

The visit was conducted as a case management incident investigation following a report of fraudulent activity by a staff member toward a resident involving unauthorized personal checks.

The facility responded quickly and effectively to the incident, suspending and terminating the implicated staff member, cross-reporting to appropriate agencies, and safeguarding the resident's cash resources. No monies were taken as the resident's bank prevented the fraudulent checks from processing.

The complaint involved fraudulent activity by Staff #1 toward Resident #1, with two personal checks totaling $8,000 made out from the resident's account. The staff member was suspended and terminated promptly. Adult Protective Services conducted a visit. No funds were lost due to bank intervention.

The visit was an unannounced complaint investigation conducted in response to allegations that staff did not evacuate a resident during a fire and that staff were not properly trained for fire evacuation.

The investigation found insufficient evidence to support the allegations. The facility had a small kitchen fire on 8/8/23, residents were instructed to stay in place per the Resident Guide, and evacuation protocols were not activated. Staff training records showed regular fire drills and training, supporting that staff were properly trained.

The complaint involved two allegations: 1) Staff did not evacuate resident during a fire, and 2) Staff not properly trained for fire evacuation. Both allegations were found to be unsubstantiated after investigation including interviews, document reviews, and observations.

The visit was an unannounced case management incident inspection triggered by a reported incident of fraudulent activity by a staff member toward a resident involving unauthorized personal checks.

The Licensing Program Analyst conducted interviews, a physical plant tour, and document reviews related to the incident. Further investigation was determined necessary before issuing a final licensing report.

The complaint involved fraudulent activity by Staff #1 toward Resident #1, with two personal checks totaling $8,000 made out from the resident's account. Staff #1 was terminated and the facility reported the incident to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement.

The inspection was conducted as a complaint investigation regarding allegations that resident records were falsified and that the facility charged residents for insurance paperwork services they did not receive.

The investigation found insufficient evidence to substantiate the allegations. Residents and staff interviews indicated that the facility charges $150 only when insurance paperwork completion is necessary, and residents receive appropriate medical services. The allegation was determined to be unsubstantiated.

The complaint alleged that the facility referred potential residents to a physician who provided false medical reports to secure insurance payments and that residents were improperly charged fees for insurance paperwork. The investigation included document review and interviews with staff and residents. The allegation was found unsubstantiated.

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

The inspection included record reviews, medication reviews, staff interviews, and a physical plant tour. No deficiencies were cited, and all reviewed areas were found to be in compliance.

The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.

The facility was found to be in compliance with regulations, with no citations issued. Observations included adequate facility layout, safety features, amenities, infection control practices, and emergency preparedness. Resident records reviewed were compliant, and staff and resident interviews were conducted.

An unannounced complaint investigation was conducted due to an allegation that the facility does not ensure an adequate quantity of food to provide to residents in care.

The investigation included observations of dining areas, interviews with residents, staff, and administrators, and review of relevant records. The allegation was found to be unsubstantiated as residents reported sufficient food quantity with alternatives available, and staff confirmed adequate meal preparation based on census and resident preferences.

The complaint alleged inadequate quantity of food for residents, with concerns that certain food items run out on some days. The investigation found this unsubstantiated based on observations and interviews.

The visit was an unannounced Case Management Deficiency inspection conducted in conjunction with an initial 10-day complaint investigation to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

The facility failed to have personnel records for 2 out of 14 staff members readily available for review by the licensing agency, which is a violation of Title 22 regulations and poses a potential risk to residents in care.

The visit was triggered by an initial 10-day complaint investigation (CC #29-AS-20240305121059). The deficiency cited was not related to the complaint but was identified during the complaint investigation.

The visit was an unannounced complaint investigation conducted to investigate allegations including that the facility administrator was not certified, staff were not TB tested, and staff did not have fingerprint clearance and association to the facility.

The investigation found the allegation that the administrator was not certified to be unsubstantiated as the administrator held a valid certificate. The allegation that staff were not TB tested was also unsubstantiated as all sampled staff had appropriate TB clearances. However, the allegation that staff did not have fingerprint clearance and association to the facility was substantiated, with three staff not having fingerprint association transferred to the facility prior to working, posing an immediate health and safety risk.

The complaint investigation was initiated based on allegations received on 2024-03-05. The allegations included that the facility administrator was not certified, staff were not TB tested, and staff did not have fingerprint clearance and association to the facility. The first two allegations were unsubstantiated, while the third was substantiated.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that the facility dishwasher was in disrepair and that facility staff were not following general food service requirements.

The allegation regarding the dishwasher being in disrepair was found to be unsubstantiated as the dishwasher was observed functioning properly and no evidence of dirty dishes was found. However, the allegation that staff were not following general food service requirements was substantiated due to uncovered and unlabeled tubs of ice cream in the freezer, posing a potential health and safety risk.

The complaint investigation was triggered by allegations received on 02/29/2024. The dishwasher allegation was unsubstantiated. The allegation that staff were not following general food service requirements was substantiated. Citations were issued and a plan of correction was required by 03/11/2024.

An unannounced complaint investigation was conducted following allegations that staff failed to act appropriately during an incident between two residents and failed to comply with reporting requirements.

The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and family members, as well as observations, did not corroborate the claims of staff inaction or failure to report the incident.

The complaint alleged that Resident #1 slapped Resident #2 in the memory care unit and staff did not intervene or report the incident. The complaint was unsubstantiated due to lack of sufficient evidence.

An unannounced complaint investigation visit was conducted to investigate the allegation that staff do not ensure hot water is available to residents.

The investigation found that on 12/29/2023, the facility was without hot water due to a scheduled shutoff to install a pressure release valve, with residents informed and provided with alternative water supplies. Interviews with nine residents revealed no immediate or potential concerns regarding hot water availability. The allegation was deemed unsubstantiated.

The complaint alleged that staff did not ensure hot water was available to residents. The allegation was unsubstantiated based on interviews and investigation findings.

The visit was an unannounced Case Management – Incident follow-up to a self-reported incident and suspected abuse involving a staff member reportedly pinching a resident to awaken them.

The investigation confirmed that Staff #1 pinched Resident #1's nipples to awaken them, causing bilateral bruising consistent with pinching. The facility cited a deficiency for violating personal rights by subjecting the resident to punishment and abuse.

The visit was an unannounced complaint investigation conducted to investigate an allegation that the facility is in disrepair due to water issues.

The investigation found that a water main burst on facility property causing flooding and water damage. The facility responded promptly by arranging repairs, providing water and food to residents, relocating affected residents temporarily, and keeping residents and families informed. The allegation was unsubstantiated as the water main burst was not conclusively due to facility neglect and the facility took timely corrective actions.

The complaint alleged that the facility was in disrepair due to water issues. The allegation was found to be unsubstantiated after investigation.

The inspection was an unannounced Case Management visit to follow up on a self-reported incident from 10/11/2023, where the facility reported that the main water line had burst and the facility water was shut off.

The Licensing Program Analyst observed gallons of water throughout the facility and resident rooms, as well as catered food. The facility had a sufficient amount of bottled water for resident and staff use. No immediate health and safety concerns were observed during the inspection.

The visit was an unannounced Case Management - Incident inspection to address a self-reported Unusual Incident/Injury Report (LIC 624) concerning an incident involving Resident #1 and two staff members on 2023-09-17.

The inspection found that staff member S1 was observed forcefully gripping and sitting Resident #1, which posed an immediate personal rights risk. Resident #1 exhibited unusual behavior and redness/bruises were noted on their arm. The facility was cited for failure to protect residents from abuse and intimidation.

The visit was complaint-related, triggered by a self-reported Unusual Incident/Injury Report involving Resident #1 and staff members S1 and S2. The complaint was substantiated by observations and staff interviews.

The visit was an unannounced complaint investigation triggered by an allegation that staff were not allowing a resident to leave the facility.

The investigation found that Resident #1 was allowed to leave the facility unassisted per physician report, and staff did not restrict residents from leaving. Interviews and record reviews confirmed the resident had left the facility on multiple occasions. There was insufficient evidence to substantiate the allegation, and it was deemed unsubstantiated.

The complaint alleged that staff were not allowing Resident #1 to leave the facility. The allegation was unsubstantiated after investigation, with no preponderance of evidence to prove the violation occurred.

An unannounced complaint investigation visit was conducted to investigate allegations that staff mishandled residents' medication and did not administer medication as prescribed.

The investigation found the allegations to be unsubstantiated based on interviews and record reviews. A similar incident had been self-reported and resolved earlier in the year. No evidence supported the current allegations at the time of the investigation.

The complaint involved allegations that staff mishandled residents’ medication and did not administer medication as prescribed. The allegations were deemed unsubstantiated after investigation. The complaint did not provide names of residents or reporting parties, limiting interviews.

An unannounced case management visit was conducted due to a fire incident in the facility kitchen on 08/08/2023.

The fire was localized to the kitchen area causing damage to ceiling panels and food, with water damage from sprinklers. There was no structural damage and kitchen equipment remained operational. The kitchen was closed pending clearance from the Department of Public Health. Residents were evacuated safely and provided meals from local restaurants during the kitchen shutdown.

Licensing Program Analysts conducted an Annual Continuation inspection to evaluate compliance with state regulations following the initial annual inspection conducted on 06/12/2023.

The inspection found deficiencies related to medication management, including discrepancies in medication pill counts and unsecured medications, as well as food safety issues such as uncovered food items, expired food, unclean kitchen areas, and improper storage of cleaning substances and disinfectant wipes.

The visit was a Case Management - Incident investigation triggered by an incident reported on 07/05/2023 involving a Memory Care resident and staff members, concerning potential resident abuse.

The investigation found that staff member S1 waved a soiled adult brief in the resident's face, humiliating the resident, which violated the resident's personal rights. Staff members involved were temporarily suspended pending internal investigation. One citation was issued related to this deficiency.

The visit was complaint-related, investigating an incident reported by the Director of Resident Care Services involving alleged abuse. The complaint was substantiated by written statements from staff confirming the incident.

The inspection was a required unannounced annual visit to evaluate the facility's compliance with Title 22 regulations.

The facility was toured inside and out, including resident rooms and common areas, with observations of compliance in most areas. However, deficiencies were cited related to water temperature exceeding safe limits in several resident rooms and accessible cleaning supplies posing a safety risk.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-15 alleging that staff did not ensure the correct medication was dispensed properly to a resident in care.

The investigation found that on 2023-02-13, a resident was administered the wrong medication (nasal spray instead of eye drops) by a new Wellness Nurse who was still in training, causing irritation and burning to the resident's eye and requiring hospital treatment. The facility staff was reactive but failed to ensure proper medication administration. The complaint was substantiated.

Complaint was substantiated. The complaint alleged staff did not ensure correct medication was dispensed properly. Investigation confirmed the medication error and related harm to the resident.

An unannounced Case Management visit was conducted to discuss COVID-19 policies and procedures, review infection control areas of concern, and assist with outbreak line list for March/April.

Two residents were observed in isolation due to COVID-19, with no staff testing positive. The facility's COVID-19 policies and procedures were reviewed, and no citations were issued during the visit.

The inspection was an unannounced complaint investigation visit conducted in response to complaints alleging inappropriate handling of a resident resulting in bruising, failure to fulfill reporting requirements, and staff not being up to date regarding resident care needs.

The investigation substantiated that staff handled a resident inappropriately causing bruising and that the facility failed to submit an unusual incident report regarding the bruising. The allegation that staff were not up to date regarding resident care needs was unsubstantiated. Deficiencies were cited related to resident rights and reporting requirements.

The complaint investigation was substantiated for allegations that staff handled a resident inappropriately causing bruising and that the facility did not fulfill reporting requirements. The allegation that staff were not up to date regarding resident care needs was unsubstantiated.

The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220826125755.

The facility did not accurately reflect Resident #2's extensive care needs in the medical assessment and care plan, posing a potential health and safety risk. Specifically, R2's care plan underestimated the assistance required for activities of daily living and transfers.

The visit was triggered by a complaint investigation under control #29-AS-20220826125755. The complaint involved concerns about Resident #2's care needs not being properly communicated or documented.

This is a pre-licensing visit for a new facility, Variel of Woodland Hills, to evaluate compliance and readiness for licensing including a dementia program and hospice waiver.

The facility was found to be in compliance with Title 22 regulations at the time of the visit. The physical plant, safety systems, amenities, infection control measures, and medication storage were all observed to meet regulatory requirements.

The visit was an initial licensing evaluation conducted via telephone call to assess the applicant and administrator's understanding of Title 22 and facility operation requirements.

The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, training, grievances, medication management, and application document review.