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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603907
Report Date: 12/05/2024
Date Signed: 12/05/2024 12:09:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
11/26/2024 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20241126113346
FACILITY NAME:POWELSON HOME IIFACILITY NUMBER:
197603907
ADMINISTRATOR:CHRISTIN SOLISFACILITY TYPE:
735
ADDRESS:16355 LONDELIUS ST.TELEPHONE:
(818) 891-2860
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anna Asuncion - DSP-House ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff failed to lock the prescibed medication.
INVESTIGATION FINDINGS:
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On 12/5/2024 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced, initial 10-day visit to investigate the above allegation. Upon arrival, LPA met with the DSP-House Manager Anna Asuncion and explained the reason for the visit.

During a physical plant tour at 10:45am, LPAs observed that the house is generally clean and organized.
At 11:00am LPAs requested and reviewed clients files and obtained copies of pertinent documents which include, but not limited to Admission Agreement, Physician Reports, Individual Program Plan (IPP), Centrally Stored Medications and Destruction Records (CSMDR), and Medication Administration Record (MAR).
At 11:15am LPA reviewed staff files and obtained copies of staff medication trainings. LPA checked medication cabinet located in the dining room. It was properly locked. LPA also observed refrigerated and found C1's Ozempic medication pen locked inside the refrigerator and inacessible to clients resideing in the facility.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 31-AS-20241126113346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELSON HOME II
FACILITY NUMBER: 197603907
VISIT DATE: 12/05/2024
NARRATIVE
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It was reported that on 11/14/24, a credible witness conducted an unannounced visit to the facility and observed C1's prescribed medication pen was stored in the refrigerator inside the unlocked bag.

During today's visit, LPA conducted interview with S1 who confirmed and stated that C1's prescribed medication pen was stored in the refrigerator, however, due to lock of knowledge that the bag needs to be locked, the medication was inside the unlocked bag.

Based on the information obtained during the interview and records review, confirmed the allegation and statements were made that the Staff failed to lock the client’s medication. The Allegation is Substantiated.


Exit interview conducted, Deficiency issued on LIC9099-D

Copy of appeal rights and report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241126113346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: POWELSON HOME II
FACILITY NUMBER: 197603907
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2024
Section Cited
HSC
80075(k)(1)
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80075 Health Related Services: (k)The following requirements shall apply to medications:(1)Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible…
This requirement is not met as evidence by:
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On 12/2/24, the Administrator conducted in service training with all staff members regarding the section cited above. The Administrator provided training materials and signatures of all staff that have completed the training to LPA on 12/5/2024.
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Based on interviews & record reviews, conducted by LPA the Administrator did not comply with the section cited above by failing to keep C1's medication locked inaccessible to 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3