195850240-5-24-2023-29-AS-JAPL-CSBMS3-20230530095113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850240
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:17:47 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
03/15/2023 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20230315132341

FACILITY NAME:	VARIEL OF WOODLAND HILLS, THE		FACILITY NUMBER:	195850240
ADMINISTRATOR:	PAYNE, KEITH		FACILITY TYPE:	740
ADDRESS:	6233 VARIEL AVE		TELEPHONE:	(818) 651-6018
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	436	CENSUS: 236	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Joyce Aquino		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not ensure the correct medication was dispensed properly to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver findings to the above facility. LPA Ascencio met with Administrator Joyce Aquino at 12:50 p.m. Entrance interview conducted.

On 03/15/2023, the Department received a complaint alleging that staff did not ensure the correct medication was dispensed properly to resident in care. Interview with Director of Resident Care Services (DRCS) Joyce Aquino at 10:30 a.m. revealed that on 02/13/2023, Resident #1 (R1) was self administered incorrect medication for their eyes. Additionally, DRCS Aquino stated Staff #1 (S1) was a new Wellness Nurse that was still training on the job and received instruction from another agency Wellness Nurse to help self administer the “eye drops” to R1. Following instruction, S1 proceeded to help with the self administration of “eye drops” into R1’s eye. R1 immediately began to complaint of irritation and burning.

Continued on LIC 9099 - C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230315132341

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: VARIEL OF WOODLAND HILLS, THE	FACILITY NUMBER: 195850240
	VISIT DATE: 05/24/2023

NARRATIVE

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S1 conducted an emergency eye wash to R1’s eye, and once R1 felt relief, proceeded to contact R1’s Ophthalmologist who advised sending R1 to the hospital for an emergency visit. DRCS Aquino stated they submitted an incident report to the Department on 02/20/2023. Lastly, upon S1’s medication error, DRCS Aquino stated S1 did not work as a Wellness Nurse until additional job training was conducted.

That same day, interview with S1, starting at 12:21 p.m. confirmed what DRCS Aquino stated. Additionally, S1 added that their shadow training was not thorough and was expedited due to a shortage in Wellness Nurses. S1 stated, once the “eye drops” were self administered, they did not panic and was able to assist R1 in rinsing their eye out. S1 stated the “eye drops” was a nasal spray. S1 proceeded to call R1’s doctor, and family representative. Lastly, S1 added that following the incident, S1 went through an intensive training for two (2) weeks where they had to shadow train with the Director of Nursing.

Even though facility staff was reactive in assisting the resident when a medication error occurred, S1 stated they did not ensure that the right medication was going to be self administrated properly. Because of this, R1 was given the wrong medication solution to their right eye causing R1 irritation, burning and being sent to the hospital. Based on evidence gathered throughout the investigation, there is sufficient evidence to support the claim that staff did not ensure the correct medication was dispensed properly to resident in care.

LPA Ascencio spoke with Administrator Aquino regarding timely reporting requirements and ongoing training for Wellness Nurses to prevent future medication errors.

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

Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230315132341

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: VARIEL OF WOODLAND HILLS, THE	FACILITY NUMBER: 195850240
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/25/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct ongoing medication training with all staff who handle medication. Administrator will submit medication plan for the year to CCL by 05/25/2023.
	8 9 10 11 12 13 14	Based on interviews, the license did not comply with the section above as an incident report, DRCS and S1 admitted to a medication error which indicated that R1 was administered nasal spray solution to their right eye which posed an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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