197608466-7-23-2024-29-AS-KLOZ-D8MTWH-20240830150533

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608466
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:55:55 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/07/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230807125538

FACILITY NAME:	BELMONT VILLAGE ENCINO		FACILITY NUMBER:	197608466
ADMINISTRATOR:	DRACHENBERG, CYNTIA		FACILITY TYPE:	740
ADDRESS:	15451 VENTURA BLVD		TELEPHONE:	(818) 788-8870
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	150	CENSUS: 117	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Abigail Traxler		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Unqualified staff are administering medication to residents.
Staff are not keeping accurate resident records.
Staff are not submitting unusual incident reports.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to deliver the findings for the allegations listed above. The LPA met with Executive Director (ED) Abigail Traxler and explained the reason for the visit.

On 08/15/2023, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial visit to investigate the allegations listed above. The LPA met with Executive Director (ED) Abigail Traxler at 10:30 a.m. and explained the reason for the visit. The LPA interviewed the staff from 11:30 a.m. to 1:00 p.m. and the residents from 1:30 p.m. to 2:00 p.m. The LPA Requested records pertinent to the investigation, a resident roster (LIC 9020), and staff roster (LIC 500).

Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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 7

Control Number 29-AS-20230807125538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 07/23/2024

NARRATIVE

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Pg. 2
Unqualified staff are administering medication to residents.
On the allegation that staff are administering medications to residents, it is the reporting party’s concern that unqualified staff are conducting blood sugar tests and giving insulin injections to residents. To investigate the allegation, LPA Urena conducted staff and residents’ interviews and reviewed documents pertinent to the allegation. Residents’ interviews revealed that they receive insulin injections from different staff. Three (3) out of five (5) residents were able to provide the names of staff who administer the injections; the names provided names were of staff who are considered skilled professionals. The staff interviewed stated that the Licensed Vocational Nurse (LVN) give the insulin injections to residents who have prescriptions for insulin, and also conduct blood sugar testing. The staff added that they have seven residents with prescriptions for insulin. Six out of seven residents have a device called either Freestyle-Libre or Dexcone attached to their arm; these devices give automatic blood sugar level readings through an application on a reading phone type device. The arm devices are changed every two weeks by the LVNs. One resident is using the Freestyle device and uses the lancet to prick their finger and get a reading through a device used for this type of blood sugar testing. The residents receive the insulin injections once to three times a day, depending on the physicians’ orders. The insulin injections are administered to the residents in the comfort of their rooms. The insulin injections are administered in the residents’ abdomen area. The insulin injections are recorded in the facility’s electronic system ‘Acuflow-Electronic Medication Administration Record(E-MAR) by the staff who administered the injections. The initials of the staff are then recorded in the E-MAR.

LPA Urena conducted record review of printouts of the E-MAR and ‘Diabetic Flow Sheet’ (DFS). During the record review, it was observed that the initials of staff 1 (S1) are printed on the DFS for resident 1 (R1) as the staff who administered the insulin injection on 08/12/2023 at 8:00 a.m. Furthermore, LPA Urena observed that the E-MAR printouts for resident 2 (R2) dated for August 2023, have the initials of staff 2 (S2), and the initials are printed on at least seven (7) different dates during the month of August 2023, which shows that S2 administered insulin injections to R2 and conducted blood sugar testing. Additionally, it was observed that the E-MAR records for R3, R4 and R5, indicate that S3 administered insulin injections and conducted blood sugar testing during the month of August 2023. Staff S1, S2, and S3 are not appropriately skilled professionals to administer injections.

Continues on Pg. 3 LIC 9099C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 29-AS-20230807125538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 07/23/2024

NARRATIVE

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Pg. 3
Based on the information obtained through interviews and record review, and although staff and residents’ interviews revealed that skilled professionals had administered the insulin injections to residents; the record review revealed that five (5) out of seven(7) residents had received either an injection or blood sugar testing from staff (S1, S2, and S3) who are not deemed based on regulations, skilled professionals. Therefore, the allegation that ‘Unqualified staff are administering medication to residents’, is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).

Exit interview was conducted. A copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 29-AS-20230807125538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/26/2024 Section Cited CCR 87629(a)(b)(1)	1 2 3 4 5 6 7	87629 (a) (b)(1)-The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following:(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Executive Director9ED) has agreed to review the regulations as they pertain to skilled professionals providing injections, and to conduct training to ensure that staff understand their roles and understand the regulations pertaining to injections provided by skilled professionals. The ED will submit proof of the training to the department by July 26th.
	8 9 10 11 12 13 14	Based on observation and record review, the licensee did not comply with the section cited above as five (5) out of seven (7) residents received injections from unskilled professionals, which poses an immediate health and safety risk to persons 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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/07/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230807125538

FACILITY NAME:	BELMONT VILLAGE ENCINO		FACILITY NUMBER:	197608466
ADMINISTRATOR:	DRACHENBERG, CYNTIA		FACILITY TYPE:	740
ADDRESS:	15451 VENTURA BLVD		TELEPHONE:	(818) 788-8870
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	150	CENSUS:	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Abigail Traxler		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Unqualified staff are administering medication to residents.
Staff are not keeping accurate resident records.
Staff are not submitting unusual incident reports.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20230807125538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 07/23/2024

NARRATIVE

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Pg 2.
Staff are not keeping accurate resident records.
On the allegation that staff are not keeping accurate resident records, it is the reporting party’s concern that medication errors have occurred due to the mishandling of medications. To investigate the allegation, LPA Urena conducted a random medication audit, and interviewed staff. During the medication audit conducted for 10 residents and compared against the Centrally Stored Medication and Destruction Record (LIC622), no errors were found. The medications are generally contained in bubble packets created by the pharmacy filling the prescriptions. The packets are labeled as AM, PM, and Night. Staff interviews revealed that the medication assistance happens at the Wellness Center (WC). Residents are accompanied by their caregivers to the WC. At the WC a med tech or a Licensed Vocational Nurse (LVN) signs in to the system, gathers the resident’s box of medications, opens the Electronic Medication Administration Record(E-MAR) scans the bubble/multi packet barcode; after scanning the barcode, a picture of the pills and the resident's picture appear on the screen and is compared to the resident standing in front of the staff. Furthermore, if a medication has been discontinued by the doctor, a red flash pops up indicating that the medication has been discontinued. The med tech or the LVN then pops the pills from the bubble packet, and hands them to the resident in a cup. Residents receive the medications along with a glass of water and take the medication in front of the staff.

Based on the information obtained through record review and staff interviews, it appears that the current facility’s system Acuflow-Electronic Medication Administration Record(E-MAR), ensures that staff keep accurate medication records, assisting with the medication, and ensuring that staff assisting with medications are recorded. Therefore, the allegation of ‘Staff are not keeping accurate resident records’ is deemed Unsubstantiated at this time.

Continues on pg 3 LIC 9099C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 29-AS-20230807125538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 07/23/2024

NARRATIVE

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Pg.3
Staff are not submitting unusual incident reports.
On the allegation that staff are not submitting unusual incident reports, it is the reporting party’s concern that facility staff are not reporting incidents and medication’s errors to the Community Care Licensing Department. To investigate the allegation, the LPA conducted record review of incidents reports and interviewed six (6) staff about the steps they follow to report incidents, which staff is responsible for filling out the incident reports (LIC 624) and submitting them to the CCLD. Staff interviews revealed that any medication errors are reported to the Director of Residents Care Services (DRCS). The DRCS submits reports to the Executive Director (ED), and the ED submits reports to CCLD. The protocol is to immediately inform the resident’s responsible party/family, and the physician of the medication error. Residents are under observation and vitals are taken for the next 24 to 48 hours, and the ED conducts an internal investigation. LPA Urena conducted an internal data system review of LICs 624 submitted by the facility to CCLD from 01/01/2023 to 07/01/2024; no LICs 624 related to medication errors were found; however, the LPA found several LICs 624 submitted by the facility to notify the CCLD about incidents that occurred at the facility.

Based on the information obtained through interviews and record review, the allegation of staff not submitting unusual incident reports could not be verified. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview was conducted. Copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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