197608083-4-9-2024-31-AS-MVAO-D49MRS-20240412095048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608083
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:14:07 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/09/2022 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20220509135641

FACILITY NAME:	OUR SWEET HOME INC #2		FACILITY NUMBER:	197608083
ADMINISTRATOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	10150 MELVIN AVE		TELEPHONE:	(818) 970-9586
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 4	DATE:	04/09/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Tina Arutyunyan (Administrator) and Hermon Ledesma (Staff)		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not administer medication to resident while in care.

INVESTIGATION FINDINGS:

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This is report is to amend the LIC9099 report issued 03/18/2024. Additional information was added to clarify the investigation pertaining to allegation mentioned above and based on new information obtained the determination for the above allegation is changed from Unsubstantiated to Substantiated.

On 04/09/2024 Licensing Program Analysts (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit to obtain additional information. Upon arrival LPA met with staff, Hermon Ledesma. Hermon contacted the Administrator, Tina Arutyunyan by telephone and LPA explained the purpose of the visit. Tina met LPA shortly after. An entrance interview was conducted. Tina provided medication administration record (MAR) for resident #2 (R2) for December 2021. Tina was unable to provide documentation showing medication for December 2021 was filled by a pharmacy or documentation resident #1 (R1) was seen by a doctor to prescribe medication after Hospice discharge date 10/14/2021. LPA interviewed Hermon Ledesma at approximately 11:30 a.m. and conducted review of current medications and medication records at approximately 2:45 p.m. (Continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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 31-AS-20220509135641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OUR SWEET HOME INC #2	FACILITY NUMBER: 197608083
	VISIT DATE: 04/09/2024

NARRATIVE

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(Continued from LIC9099)
Administrator could not stay to sign todays report and designated Hermon Ledesma, staff to sign.
Allegation: Staff did not administer medication to resident while in care. It is alleged facility failed to provide medication during the time R1 was discharged from Hospice. To investigate this allegation on 05/17/2022 LPAs Joscelyn Martinez and Tuesday Cabiness conduct an the initial complaint visit. Review of Medication Administration Records (MAR) on 05/17/2022 for the time period in question revealed medication listed on MAR was checked off as being provided after Hospice discharge date of 10/14/2021 to 12/16/2021 but not checked off as being provided from 12/17/2021 to 12/31/2021. Facility is not able to provide MAR or Centrally Stored Medication or Destruction Records for the first week of January 2022 before R1 was sent to the hospital. LPA Martinez notes Medication documentation picks up again on February 2022. On 05/17/2022 LPAs Martinez and Cabiness conducted interviews with four (4) out of four (4) residents and on 03/18/2024, LPA Rios conducted interviews with 4 out 4 residents. Resident interviews revealed they cannot recall experiencing missed medication, or medication errors. According to interview on 03/18/2024 with staff responsible for assisting residents with medication they deny the allegation and they state they have always provided medication as directed. Interview with staff on 04/09/2024 revealed they cannot recall why MAR was not filled in for 12/17/2021 to 12/31/2021, but they are certain medication was provided. Interview on 05/17/2022 with staff revealed that during that time they forgot to fill MARs for the month of January 2022. On 04/03/2024 LPA Rios conducted an interview with a representative from R1's former hospice agency that revealed, Hospice handled prescribing and making sure medications were filled by Hospice pharmacy for R1. Furthermore, Hospice agency representative revealed they would have provided at most a 2 to 4 weeks supply of medication after discharge date of 10/14/2021, while R1 made an appointment with primary doctor. Interview with administrator on 03/18/2024 and again on 04/09/2024 still denies the allegation and they state medication has always been provided. Review of records on 04/09/2024 revealed, facility kept medication administration records (MAR) for December 2021 to document medication assistance. MAR for residents during the month of December 2021, revealed resident #2 (R2) unlike resident #1 (R1) was not missing recorded days of medication for 12/17/2021 to 12/17/2021. Indicating facility failed to properly record medication administration for R1. Based on facilities own MAR documentation showing the discrepancy between R1 and R2 and the facility unable to provided documentation for R1 showing medication was filled by a pharmacy or a medication list provided by a doctor for time period 12/17/2021 to 01/06/2021 the determination for allegation; staff did not administer medication to resident while in care is Substantiated.

Deficiency cited (refer to LIC9099D). Appeals discussed and provided. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220509135641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OUR SWEET HOME INC #2	FACILITY NUMBER: 197608083
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/10/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Review of residents medication records for the month of May 2022 were noted as in compliance by LPA Martinez. Review of medication and medication records for April 2024 reviewed by LPA Rios are in compliance.
	8 9 10 11 12 13 14	Based on LPA's observation and record review, the facility failed to provide records, showing medications were provided to R1 from 12/17/2021 to 01/06/2022 which poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14	Based on current medication compliance administrator will provide to LPA a statement of understanding for the cited regulation by POC due date.
	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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC9099 (FAS) - (06/04)

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