197608280-4-4-2024-29-AS-DPEA-D4T2B7-20240429171440

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:59:03 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
03/28/2024 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20240328080922

FACILITY NAME:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	CLARIZZE PUNIT		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 27	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Clarizze Punit		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not following physician’s orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced initial complaint investigation for the above allegation. Upon arrival, LPA with the Administrator, Clarizze Punit and the reason for the visit was explained. Entrance interview.

During today’s visit, LPA toured the facility to ensure there are no health or safety concerns at 10:30 a.m., conducted interviews with the Administrator and one staff between 10:23 a.m. and 10:57 a.m., conducted a resident file review at 11:05 a.m., and obtained copies of pertinent documents relevant to the investigation.

It was alleged that staff are not following physician’s order. It was reported that Resident #1 (R1) is to receive Hydrocodone – Acetaminophen (Norco) every eight (8) hours and as needed, but facility staff is only providing Norco to R1 every other day.

Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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-20240328080922

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: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 04/04/2024

NARRATIVE

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Continued from LIC 9099...

Information obtained and records reviewed revealed that per R1’s physician’s report dated 09/14/2021, R1 is able to follow instructions and is able to communicate their needs. Additionally, the LPA reviewed physician orders dated 12/12/2023 and 03/14/2024, which indicated R1 was prescribed Norco 5-325mg, one (1) tablet every eight (8) hours as needed for severe pain. The LPA reviewed the Narcotic Medication Record starting on 12/13/2023 and noted that R1 was given Norco for pain consistently from 12/13/2023 to 03/23/2024 in the mornings upon waking up; and more recently noted R1 was also given Norco in the evenings on 03/15/2024, 03/17/2024, 03/19/2024, and 03/23/2024. Interviews conducted with staff revealed that R1 would request Norco upon waking up due to pain and added that they would offer R1 Norco in the evenings when R1 appeared to be in pain but was not communicating symptoms with staff. Staff also added that R1 would request more Norco shortly after receiving it; however, they are required to follow the physicians order which stated, “one orally every 8 hours as needed for severe pain… Do not exceed 3 tablets in 24 hours”. Furthermore, Norco was prescribed to R1 as a PRN to take once every eight (8) hours as needed for pain and not every eight (8) hours and as needed. Based on the information obtained and reviewed, there is insufficient evidence to support the allegation of “staff are not following physician’s order”. Therefore, this allegation is being deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Copy of the report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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