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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 194700292
Report Date: 04/26/2024
Date Signed: 04/26/2024 09:31:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2024 and conducted by Evaluator Joshua Rarela
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20240105110439
FACILITY NAME:WALNUT ACRES COMPANION & CARE SERVICESFACILITY NUMBER:
194700292
ADMINISTRATOR:CALDWELL, SUSANFACILITY TYPE:
300
ADDRESS:22907 OXNARD STTELEPHONE:
(818) 383-9233
CITY:WOODLAND HILLSSTATE: ZIP CODE:
91367
CAPACITY:CENSUS: DATE:
04/26/2024
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Susan CaldwellTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Home Care Aides administered medical services to a client
INVESTIGATION FINDINGS:
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On April 26, 2024 at 12:10 PM, Associate Governmental Program Analyst (AGPA) Joshua Rarela conducted a follow-up complaint investigation concerning the allegation above.

AGPA met with the facility licensee, Susan Caldwell, at the Home Care Organization facility located at 22907
Oxnard Street, Woodland Hills, CA 91637. During the course of the investigation, AGPA interviewed the
complainant, the former Home Care Aides (HCAs), and the licensee; AGPA also reviewed records including but not limited to photographs, Caregiver/Companion Care Agreement, licensee public website and listed duties of HCAs.

(CONTINUED)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Susan Du
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
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 47-HC-20240105110439
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME: WALNUT ACRES COMPANION & CARE SERVICES
FACILITY NUMBER: 194700292
VISIT DATE: 04/26/2024
NARRATIVE
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An HCA interviewed admitted to the AGPA that they assisted the client with an insulin injection, which was in the form of an insulin pen, on multiple occasions when the client was unable to do the insulin injection on their own. The other HCAs stated that their duties were limited to providing the client assistance with services related to "Activities of Daily Living" (ADL) that included assisting the client with eating, bathing, dressing, toileting and personal hygiene and denied assisting the client with their insulin injection and other medical related services.

Based on AGPA's observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Health and Safety Code. Article 1. Section 1796.12 (n), are being cited on the attached HCS9099-D.

A copy of the reports and appeal rights were provided to the facility representative.
SUPERVISORS NAME: Susan Du
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 47-HC-20240105110439
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME: WALNUT ACRES COMPANION & CARE SERVICES
FACILITY NUMBER: 194700292
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2024
Section Cited
1796.12 (n)
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Home care services means nonmedical services and assistance provided by a registered home care aide to a client who, because of advanced age or physical or mental disability, cannot perform these services. These services enable the client to remain in his or her residence and include, but are not limited to, assistance with the following: bathing, dressing, feeding, exercising, personal hygiene and grooming, transferring, ambulating, positioning, toileting and incontinence care, assisting with medication that the client self-administers, housekeeping, meal planning and preparation, laundry, transportation, correspondence, making telephone calls, shopping for personal care items or groceries, and companionship. This subdivision shall not authorize a registered home care aide to assist with medication that the client self-administers that would otherwise require administration or oversight by a licensed health care professional.
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Per the licensee, the final service date for the client was in January 2022. All of the HCAs assigned to the client are no longer employed by the licensee.

The licensee agreed to provide re-training on the cited statute to all current HCAs employed by the
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This requirement is not met as evidence by:
Based on the information obtained, it was
determined that an HCA assisted a client with insulin injections on multiple occassions when the client was unable to do it on their own, a finding which poses an immediate Health and Safety risk to clients in care.
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licensee by the POC due date instructing them that they are not authorized to assist with medication that the client self-administers that would otherwise require administration or oversight by a licensed health care professional.

The licensee will follow-up with the AGPA on the training records as proof of the re-training.
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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: Susan Du
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3