195850091-5-10-2022-29-AS-JAPL-CGCS5F-20220715133410

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:23:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211203112208

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	WILLIAMS, CELESTE		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(818) 922-8980
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 15	DATE:	05/10/2022
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Eileen Esquivel		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff failed to assist resident with the self-administration of medication
Incomplete files

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent visit. The LPA met with Executive Director Eileen Esquivel and explained the reason for the visit.

On 12/10/2021, LPAs Ashley Smith and Elsie Campos conducted a physical plant tour at 1:55 p.m., conducted a file review at 2:59 p.m. and interviewed staff at 2:10 p.m. On 4/16/2022, the LPAs conducted a tour at 1:20 p.m., conducted a file review at 11:00 a.m. and interviewed staff at 11:50 a.m., 12:23 p.m., 1:00 p.m., 3:20 p.m., and 3:49 p.m. During today’s visit, the LPA conducted a medication audit from 2:15 p.m. – 3:30 p.m., and audited files from 3:30 p.m. – 4:00 p.m. In addition, the LPA reviewed the Medication Administration Record (MAR) for Resident #1 (R1). In addition, the LPA subpoenaed medical records on 4/18/2022 and received the records on 4/20/2022.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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 4

Control Number 29-AS-20211203112208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 05/10/2022

NARRATIVE

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Regarding the allegation: Staff failed to assist resident with the self-administration of medication
It was alleged that R1 did not receive their medications. Today, the LPA reviewed the Medication Administration Record (MAR) for R1 for November 2021. The MAR revealed that R1 did not receive assistance with several medications due to the medication not being in the facility. The LPA observed that on the medication notes, staff indicated that medications were either ‘not available’ or ‘med not on hand’. For example, R1 had a missed dosage of Eliquis nine (9) times from 11/7/2021-11/14/2021; missed twelve (12) dosages of Magnesium Oxide, Vitamin D3, and Vitamin C, Vitamin B-12 from 11/6/2021 – 11/29/2021; and missed eleven (11) dosages of Senna from 11/7/2021 – 11/22/2021. Staff interviews confirmed that the staff whom assisted with R1 with the self-administration of medication are no longer working at this location.
During today’s medication audit, the LPA audited medications for three residents. Two out of three residents (Resident #2, Resident #3) had PRN medications; however, the PRN medication documentation log was inaccurate. The facility plans to have a full medication audit completed by their regional nursing staff within the next two weeks.

Based on the investigation, there is sufficient evidence to support the claim that the staff failed to assist resident with the self-administration of medication. This allegation is deemed Substantiated at this time.

Regarding the allegation: Incomplete files

It was alleged that the staff and resident files were incomplete. During the investigation, the LPA conducted a file audit on 12/10/2021 and during today’s visit. It was discovered that out of the thirteen (13) files audited, two out of thirteen staff needed valid first aid/CPR certification (S2, S3), one out of thirteen staff failed to have a completed job application on file (S1), and one out of thirteen staff needs a completed health screening (S2). However, staff communicated that they have been auditing files to ensure that all paperwork is in order.

Based on the investigation, there is sufficient evidence to support the claim that the files were incomplete. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211203112208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/12/2022 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Host an in-service training around the self-administration of medications, specifically discussing PRN documentation, protocol when medications require refills, and completing the Centrally Stored Medication and Destruction Record.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply in the section cited above for three out of three residents (R1, R2, R3), which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Submit the training sign-in sheet to CCL no later than 5/12/2022.
Type B 05/20/2022 Section Cited CCR 87412(a)	1 2 3 4 5 6 7	87412(a) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Audit the files for staff currently working in the facility. Inform the Department when this is complete and all files are in order, but no later than 5/20/2022.
	8 9 10 11 12 13 14	Based on records review, the licensee did not comply in the section cited above for three out of thirteen staff members, as their files were incomplete, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC9099 (FAS) - (06/04)

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