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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602726
Report Date: 12/19/2022
Date Signed: 12/20/2022 08:43:36 AM

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
04/05/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20220405114844
FACILITY NAME:ETTA ISRAEL CENTER ADULT RESIDENTIAL #1FACILITY NUMBER:
197602726
ADMINISTRATOR:HEIDI SCHOFIELDFACILITY TYPE:
735
ADDRESS:5520 WORTSER AVENUETELEPHONE:
(818) 785-2054
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
12/19/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Samuel FormanTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not assist resident(s) with the self-administration of medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Emily Peraldi and Ashley Smith, conducted an unannounced subsequent complaint visit at the facility today. At 9:35 a.m., the LPAs met with facility staff and explained the reason for the visit. At 11:55 a.m., the LPAs spoke with the Administrator, over the phone. The Administrator was not available during the time of the visit and authorized staff, Samuel Forman to sign the report.

During the initial complaint visit on 04/13/2022, between 10:42 a.m. and 11:55 a.m., LPA Peraldi toured the facility and reviewed client records. on 04/13/2022, between 11:56 a.m. and 3:19 p.m., LPA Peraldi interviewed six (6) out of six (6) clients and three (3) staff. On 04/13/2022, at 10:21 a.m., LPA Peraldi interviewed the Administrator. On 04/13/2022, at 11:50 a.m., LPA Peraldi obtained copies of pertinent documents and conducted a medication audit. During todays visit, at 9:41 a.m., the LPAs along with staff conducted a physical plant tour. Between 10:04 a.m. and 11:50 a.m., LPA Peraldi conducted interviews with two (2) staff and one (1) client. At 10:25 a.m., the LPAs conducted a medication audit for five (5) out of six (6) clients. Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
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 5
Control Number 29-AS-20220405114844
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: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726
VISIT DATE: 12/19/2022
NARRATIVE
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On 12/12/2022, the Department received a complaint in which it was alleged that the staff are not assisting with self-administration of medications. During the medication audit the following was noted:

- Client #1 (C1): The current start date per the centrally stored medication and destruction record for Vitamin D3 was 12/01/2022., There was six (6) pills left in the bubble pack; if it were properly distributed, C1 would have nine (9) pills remaining in the bubble pack.

- Client #2 (C2): The current start date per the centrally stored medication and destruction record for Fluconazole was 11/30/2022. There was four (4) pills left in the bubble packet; if it were properly distributed, C2 would have three (3) pills remaining in the bubble pack. Per physician’s order, Fluconazole is to be taken 1 tablet by mouth every three (3) days, however for 12/11/2022 the pill is still in the bubble indicating that staff did not properly assist C2 with the self-administration of the above medication. Interviews with staff revealed that C2 went home during the time of the medication error.

- For Client (C3) #3 , the current start date per the centrally stored medication and destruction record for Oxybutynin was 11/30/2022. There was six (6) pills left in the bubble pack; if it were properly distributed, C3 would have eight (8) pills remaining in the bubble pack.

- For client (C3) #3 , the current start date per the centrally stored medication and destruction record for the Metamucil 30 pack was 10/23/2022. As of today, there 11 packs remaining. Whereas staff claimed that C3 was assisted with the self-administration of this medication daily, staff were unable to clarify the discrepancy, as all of these packs should have been dispensed to the client and a new medication packet should have begun. -

Per medication audit and interviews throughout the investigation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220405114844
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: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726
VISIT DATE: 12/19/2022
NARRATIVE
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Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220405114844
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: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2022
Section Cited
CCR
80075(b)
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80075(b) 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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The Administrator agreed to do the following:
1. Schedule a training regarding 80075 Health Related Services. Verification of scheduled training with the trainers credentials will need to be submitted by 12/20/2022 and completion of training must be submitted no later than 01/02/2023.
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Based on observation and interview, the licensee did not comply with the section cited above, as medication errors were observed for five (5) out of six (6) clients, which poses an immediate health and safety risk to clients 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5