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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850156
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:55:50 AM

Unsubstantiated


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
08/31/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20230831122027
FACILITY NAME:CNS QUAKERTOWNFACILITY NUMBER:
195850156
ADMINISTRATOR:MARC SAINT CLAIRFACILITY TYPE:
735
ADDRESS:5135 QUAKERTOWN AVENUETELEPHONE:
(661) 872-3408
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:6CENSUS: 6DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Residential Manager Jacqueline JuarezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Residents are transferred without the required amount of staff necessary to assist

Staff are not adequately trained

Staff mixed resident medication with a pencil
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Residential Manager Jacqueline Juarez and explained the reason for the visit.

On 09/05/2023, from 10:30 a.m. to 01:00 p.m., LPA Balisi conducted an unannounced complaint visit. At approximately 10:30 a.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documents relevant to the investigation. On 01/24/2024, LPA conducted interviews with additional staff and responsible parties of residents in care while conducting a subsequent visit on a separate investigation.
It was reported that "Residents are transferred without the required amount of staff necessary to assist" , as it was alleged that Resident #1 (R1) was not being transferred without the required amount of staff.
Interviews and record reviews showed Resident #1 (R1) was not admitted into this facility and staff do not remember R1 ever being admitted to this facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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 29-AS-20230831122027
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: CNS QUAKERTOWN
FACILITY NUMBER: 195850156
VISIT DATE: 10/03/2024
NARRATIVE
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Continued from 9099
However, Resident #2 (R2) who was admitted on 11/18/2022, did require help transferring in and out of their wheelchair when they first arrived, but as R2 got closer to discharge on 09/29/2023, they needed less assistance and no longer required two staff members to help. LPA's interviews with five (5) staff members, revealed that there has always been enough staff available on every shift to assist clients who needed two person help. LPA’s interview with four (4) families / responsible parties of residents in care at the time of the complaint revealed all (4) have not observed insufficient staffing and each did not express any concerns for lack of staffing at this time. Interviews and records review of staff schedule revealed there are two (2) caregivers scheduled during NOC shift and there are at least three (3) caregivers during the AM and PM shift. Also present in the home is the Administrator and nurse during the morning and afternoon shifts Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Residents are transferred without the required amount of staff necessary to assist” is deemed Unsubstantiated at this time.

It was reported that "Staff are not adequately trained", as it was alleged that staff are required to feed R2 without the adequate training. Interviews and records review revealed all staff must participate in G-Tube Training. There at least three (3) full trainings before handling any residents with a g-tube, which includes a verbal instructive training, a hands on training, a practice training, then they begin to service the resident while staff standby and observe. The entire training encompasses the following: check G-Tube Orders, Gathers equipment (Feeding, syringe, or gravity bag, water (if prescribed), gloves, washes hands and puts on gloves, positions client comfortably and as prescribed, Remove G-tube cap and insert syringe, un-clamp tubing (if applicable), check residual and hold feeding (if applicable) according to physicians orders. Pour feeding syringe and allow to flow, or if button-insert extension tube, turn to lock into place, insert syringe, un-clamp and pour feeding into syringe, allow to flow. Continue to pour feeding into syringe until feeding completed, raise or lower syringe to adjust flow as needed, when feeding complete, pour prescribed amount of water (if applicable), clamp tubing, remove syringe, & re-clamp g-tube, if button clamp extension, turn to unlock, remove syringe and extension, replace clamp, remove gloves and wash hands, wash out syringe, allow to dry and put with other equipment for next feeding, and document feeding preformed and tolerated. LPA's records review of five (5) randomly selected staff files revealed G-Tube training.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230831122027
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: CNS QUAKERTOWN
FACILITY NUMBER: 195850156
VISIT DATE: 10/03/2024
NARRATIVE
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Continued from 9099-C

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff are not adequately trained” is deemed Unsubstantiated at this time.

It was reported that "Staff mixed resident medication with a pencil" as it was alleged that staff mixed R2's medication with a pencil and inserted the medication into R2's tube feeder. Interviews conducted with five (5) staff revealed that all (5) staff have never witnessed any staff mix any residents medication with a pencil. Each staff interviewed also did not express any potential or immediate concerns for any staff when administering medication to the residents. LPA’s interview with four (4) families / responsible parties of residents in care at the time of the complaint revealed all (4) have never observed staff mix medication with a pencil. Each family / responsible party interviewed also did not express any concerns for staff administering medication at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff mixed resident medication with a pencil” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3