Complaint Investigation Report

During today’s visit between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. No immediate concerns were observed. The following was then determined:

Allegation: “Staff did not report an incident to licensing.”

It was reported that the facility did not notify Community Care Licensing (CCL) of an unwitnessed fall. On 07/26/2025, Resident #1 (R1) sustained an unwitnessed fall in their unit and was found on the floor by their bedside. The facility notified R1’s family and R1 was subsequently transferred to the hospital via Emergency Services. Interview with five (5) out of seven (7) staff revealed that they were unaware about the CCL reporting requirements, or if facility incidents were reported to CCL. Staff responsibilities include logging incidents in the facility’s electronic system and facility Administrators are responsible for the remaining steps. Interview with the ED noted that they “assumed Licensing received the report” of R1’s fall. When the LPA inquired about the details of the fall, the ED requested to review the copy the LPA obtained and provided information off the Incident Report.

On 11/05/2025, the LPA conducted an unrelated complaint visit and addressed facility Incident Reports with the Office Manager Joey Vitug. The Office Manager is responsible for completing Incident Reports and sending them to CCL. They stated they utilize an App called Genius Scan that scans the Incident Reports which processes and automatically emails CCL the reports.

During the visit on 11/13/2025, the LPA reviewed CCL’s record of Incident Reports received from 2024 to present with the ED, the incident on 07/26/2025 not included as it was not received. The ED expressed and confirmed that the record did not reflect the accurate number of incidents the facility has experienced. The LPA addressed the Genius Scan App and suggested that the facility email all reports to the Woodland Hills North Regional Office directly to ensure receipt and compliance. The ED agreed.