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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197600716
Report Date: 06/22/2022
Date Signed: 09/12/2022 02:33:02 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220512124153
FACILITY NAME:VISTAS HOMEFACILITY NUMBER:
197600716
ADMINISTRATOR:JASSO,CARLOSFACILITY TYPE:
735
ADDRESS:16778 OTSEGO ST.TELEPHONE:
(818) 784-1680
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:4CENSUS: DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Physician's orders were not followed.
Reporting guidelines were not followed.
INVESTIGATION FINDINGS:
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This is an amendment of the report issued on 06/22/2022 to edit details related to the findings.
Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequent complaint visit to investigate the above allegations. LPA met with the Administrator, Carlos Jasso, and explained the reason for the visit.

--- Physician's orders were not followed.
It was alleged that there were several medication errors at the facility. To investigate this allegation, on 05/16/2022, LPA interviewed staff from 10:30 AM - 11:30 AM and requested records. Although the medication records did not indicate that there were any errors, interviews with staff revealed that medications were not administered according to the physician's orders for Resident #1 and Resident #2.

Based on the information revealed during interviews and record review, the allegation is SUBSTANTIATED at this time.
(Cont. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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 3
Control Number 31-AS-20220512124153
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VISTAS HOME
FACILITY NUMBER: 197600716
VISIT DATE: 06/22/2022
NARRATIVE
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--- Reporting guidelines were not followed.

It was alleged that there was a lack of incident reporting about the medication errors. To investigate this allegation, on 05/16/2022, LPA interviewed staff from 10:30 AM - 11:30 AM and conducted a record review. Interviews and record review revealed that the facility did not submit an incident report timely.

Based on the information revealed during interviews and record review, the allegation is SUBSTANTIATED at this time.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the
Administrator. A copy of this report, LIC 9099-D, and Appeal Rights were discussed and provided to
Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20220512124153
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VISTAS HOME
FACILITY NUMBER: 197600716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by;
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Administrator will submit a detailed written plan notifying the department what steps will be taken to prevent medications errors from occurring.
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Based on interviews and record review, the licensee did not ensure that medications were administered according to physician's orders which poses an immediate health and safety risk to residents in care.
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Type B
06/27/2022
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements: (b)Upon the occurrence...a report...shall be submitted to the licensing agency within seven days following the occurrence of such event.(1) Events reported shall include the following: E) Any unusual incident or client absence which threatens
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Administrator has agreed to submit in writing how they will ensure that the facility follows all reporting requirements according to regulations.
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the physical or emotional health or safety of any client. This requirement was not met, evidenced by: Based on interviews and record review, the facility did not submit or report incidents pertaining to medication errors which poses a potential health and safety to risks to residents in care.
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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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3