197607880-11-22-2024-29-AS-DPEA-DBEQ3A-20241127104824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607880
Report Date: 11/21/2024
Date Signed: 11/22/2024 04:35:51 PM

Unsubstantiated

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
04/24/2024 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20240424152441

FACILITY NAME:	FOUNTAINVIEW AT EISENBERG VILLAGE		FACILITY NUMBER:	197607880
ADMINISTRATOR:	ADAM PENA		FACILITY TYPE:	741
ADDRESS:	6440 WILBUR AVENUE		TELEPHONE:	(818) 654-5534
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	216	CENSUS: 106	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Adam Pena		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff are not ensuring that an appropriately skilled professional is assisting the resident with injections

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit regarding above allegation. Upon arrival LPA met with Administrator Adam Pena and Director of Health Services Clarissa Townes. Reason for visit was stated.

Following is a summary of the allegations and investigation findings:
Regarding allegation, “Facility staff are not ensuring that an appropriately skilled professional is
assisting the resident with injections” – It was alleged that a caregiver is providing medication injection to resident #1. On 04/24/20224, Community Care Licensing Division (CCLD) received a complaint with the above allegation. Investigation was initiated on 05/01/2024, a physical plant tour was conducted, and allegation was discussed with administrator. Resident roster and private caregiver list was obtained. A subsequent visit was conducted on 07/17/2024 and 11/21/2024. Interviews were conducted with (10) residents, (3) staff and potential witnesses. Additional interviews were conducted by phone on 07/24/2024 and 07/25/2024. (Continue to LIC 9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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-20240424152441

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: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
	VISIT DATE: 11/21/2024

NARRATIVE

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According to the Director of Health Care Services Maria Rona Perez. Facility caregivers and private caregivers are not allowed to provide any type of injection to resident. Executive Director (ED) Adam Pena stated that the facility does have a nursing staff and only a skilled professional would provide injections. Facility staff and private caregivers interviewed reported that they do not provide any injection to residents. Resident #1 (R1) was interviewed and confirmed handling own medications and is not on the facility med-management program at this time. Ms. Perez also confirmed that R1 is not on facility’s med-management program at this time and is not receiving any injections. Centrally stored medication records reviewed did not show R1 on any injections. Ten out ten random residents interviewed did not report any issues or concerns with the facility. All ten residents interviewed stated that they administer their own medications.

Ms. Perez stated that they arrange a meeting with the resident, and families, when there is significant change in the resident’s condition, and once every 6 months to determine level of care change including but not limited to med-management. Mr. Pena and Ms. Perez both denied the allegation and stated that they are not aware of any caregiver or private caregiver assisting resident with injections. Mr. Pena stated that they will remind all staff, private caregivers, residents, and families of the facility policy regarding medications specifically “injections” which are to be provided only by the skilled professional (facility nurse).

Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff are not ensuring that an appropriately skilled professional is assisting the resident with injections” is deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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