197607123-4-17-2023-31-AS-NMAN-D2EQXW-20240213113413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607123
Report Date: 04/17/2023
Date Signed: 04/17/2023 04:15:28 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
02/14/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230214165012

FACILITY NAME:	ENCINO LIVING		FACILITY NUMBER:	197607123
ADMINISTRATOR:	O. ALMANY & D. PETRASEK		FACILITY TYPE:	740
ADDRESS:	16710 MAGNOLIA BLVD.		TELEPHONE:	(818) 907-1343
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 5	DATE:	04/17/2023
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Maria Claro		TIME COMPLETED:	04:18 PM

ALLEGATION(S):

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Staff not appropriately administering medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 2:00 pm. LPA Smith met with staff and disclosed the purpose of this visit.

On 03/13/23 and 03/20/23. LPA Smith delivered findings for six of seven allegations.
During initial visit, on 02/21/23, LPA Smith conducted tour of physical plant, conducted interviews with staff and requested documents relevant to the investigation.

Staff not appropriately administrating medication.
It was alleged that staff are not appropriately administrating medication to residents in care and medications are not safeguarded. On 02/21/23, 03/13/23,03/20/23, and during today’s visit LPA observed medication locked and stored in hall closet. LPA did not observe any medication left out or accessible to residents.
(Cont to 809)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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-20230214165012

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: ENCINO LIVING	FACILITY NUMBER: 197607123
	VISIT DATE: 04/17/2023

NARRATIVE

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(Cont from 809)

However, review of residents medication and Medication administration record (MAR) for 04/17/23, show that signatures for the AM medication for Resident #1 (R1) were missing or not logged on the MAR. LPA Smith interview with Staff #1 (S1) revealed that they sign the MAR noting they administered the AM medications at the end of their shift not once administered to the resident.

Based on review of MAR and interviews, there is sufficient information to support this allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230214165012

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: ENCINO LIVING	FACILITY NUMBER: 197607123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/17/2023 Section Cited CCR 87465(D)(2)	1 2 3 4 5 6 7	If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication […] facility staff designated by the licensee, shall be permitted to assist the resident [...] the physician's directions, shall be documented and maintained in the resident's facility record.	1 2 3 4 5 6 7	The Licensee/Administrator will have certified vendor to provide medication administration training for designated staff for year 2023. POC: 05/15/2023
	8 9 10 11 12 13 14	The requirement was not met based on: Discrepancy on medication administration record was observed for (R1). It was not clear if R1 received medication at designated time per doctors’ instructions. This poses a risk for 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC9099 (FAS) - (06/04)

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