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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608478
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:52:53 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/29/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20220929105301
FACILITY NAME:SUNRISE ASSISTED LIVING OF WOODLAND HILLSFACILITY NUMBER:
197608478
ADMINISTRATOR:BENITO DEL TOROFACILITY TYPE:
740
ADDRESS:20461 VENTURA BLVDTELEPHONE:
(818) 346-9046
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:127CENSUS: 68DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patrice O Grady TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not keep accurate medication log

Staff did not follow doctor’s orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver findings of the allegations listed above. Upon arrival LPA met with Executive Director Patrice O’Grady and explained the reason for the visit.

On 09/29/2022, the Department received a complaint regarding allegations that Staff did not follow doctor’s orders and Staff did not keep an accurate medication log.
On 09/30/2022, from 1:30pm to 4pm, LPA conducted an unannounced initial complaint visit and conducted a physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation.
On 12/15/2022, LPA conducted a subsequent visit and conducted a physical plant tour, a medication audit for (7) memory care residents, interviewed staff and reviewed and obtained additional pertinent documents relevant to the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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 5
Control Number 29-AS-20220929105301
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: SUNRISE ASSISTED LIVING OF WOODLAND HILLS
FACILITY NUMBER: 197608478
VISIT DATE: 01/13/2023
NARRATIVE
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Continued from 9099

It was reported that staff did not keep an accurate medication log as it was alleged that S1 did not document that R1 was administered a dosage Pantoprazole (40mg, 1 tablet daily) resulting in R1 receiving (2) dosages of Pantoprazole (40mg, 1 tablet daily) when the physician order calls for only (1) dose. LPA’s review of R1s medication records revealed R1 is to be administered (1) dose of Pantoprazole (40mg, 1 tablet daily). Records review and LPA's interview with staff and responsible parties revealed that on 09/24/2022, at the beginning of S2s shift at approximately 2pm, S2 reviewed R1s medication log and observed R1 had yet to receive their daily dose of Pantoprazole (40mg, 1 tablet daily). S2 proceeded to administer that medication, however interviews and records review further revealed that R1's responsible party administered Pantoprazole (40mg, 1 tablet daily) in the morning and it was witnessed by S1. Interview with S1 revealed confirmation that they observed R1s responsible party administer the medication, but S1 did not document it in R1's medication log resulting in R1 receiving (2) dosages when the physicians orders requires only (1) dosage daily. LPAs medication Audit of (7) residents in memory care revealed that all medications appeared to have been administered as prescribed at this time. Based on information gathered during this and previous visits, the department has sufficient evidence to prove this allegation occurred. Therefore the allegation that Staff did not keep an accurate medication has been deemed SUBSTANTIATED at this time.

It was reported that Staff did not follow doctor’s orders as it was alleged that medication was Administered to R1 when there was a physician's order, that stated to Hold on administering Tramadol 50mg until 08/26/2022. LPA records review of R1's medical file revealed a physicians order to hold the administration of one of R1s medication from 08/18/2022 to 08/26/2022. Review of Medication Administration Logs revealed R1 was administered the medication on the morning of 08/25/2022 between 6am - 10am. Based on information gathered during this and previous visits, the department does have sufficient evidence to prove this allegation occurred. Therefore the allegation that staff did not follow doctor's orders has been deemed SUBSTANTIATED at this time.

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


Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220929105301
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: SUNRISE ASSISTED LIVING OF WOODLAND HILLS
FACILITY NUMBER: 197608478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4)Incidential Medical and Dental Care - A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care… The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Licensee has agreed to hold a staff meeting to review regulation and provide LPA with sign-in sheet for all who attended via email by 01/20/2023.
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Licensee did not ensure the safety of R1, as interviews with staff and responsible parties along with medical records review revealed R1’s medication administration records was not accurately kept resulting in R1 receiving a second dose of a once daily med, which poses as a potential health and safety risk to residents in care.
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Type B
01/20/2023
Section Cited
CCR
87465(C)(2)
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87465(C)(2) Incidental Medicala and Dental Care If the resident's physician has stated in writing that the resident...Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidence by:
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Licensee has agreed to hold a meeting to review regulation and provide LPA with sign-in sheet for all who attended via email by 01/20/2023
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LPA interviews and review of R1’s medical records revealed Licensee did not ensure physician’s orders were followed resulting R1 being administered a medication that was ordered to be put on hold by Primary care physician, which poses a potential health and safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/29/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20220929105301

FACILITY NAME:SUNRISE ASSISTED LIVING OF WOODLAND HILLSFACILITY NUMBER:
197608478
ADMINISTRATOR:BENITO DEL TOROFACILITY TYPE:
740
ADDRESS:20461 VENTURA BLVDTELEPHONE:
(818) 346-9046
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:127CENSUS: 68DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patrice O Grady TIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident’s medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver findings of the allegations listed above. Upon arrival LPA met with Executive Director Patrice O’Grady and explained the reason for the visit.
On 09/29/2022, the Department received a complaint regarding allegations that Staff mismanaged resident’s medication.
On 09/30/2022, from 1:30pm to 4pm, LPA conducted an unannounced initial complaint visit and conducted a physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation.
On 12/15/2022, LPA conducted a subsequent visit and conducted a physical plant tour, a medication audit for (7) memory care residents, interviewed staff and reviewed and obtained additional pertinent documents relevant to the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220929105301
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: SUNRISE ASSISTED LIVING OF WOODLAND HILLS
FACILITY NUMBER: 197608478
VISIT DATE: 01/13/2023
NARRATIVE
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Continued from 9099

It was reported that staff mismanaged resident's medication as it was alleged that staff was unable to locate the Pantoprazole (40mg, 1 tablet daily) medication after delivery to the facility. LPAs interview with Staff 1 (S1) revealed S1 signed to receive package at the front desk in the evening of 9/23/2022 at approximately between 5:30pm - 6pm. LPAs interview with (6) other staff revealed that facility protocol indicates that when new medication is received it has to be reviewed and inputted into their system by Nurse on duty. There was no nurse on duty at the time the medication was received so S1 put medication in a secure location in a locked box inside of Staff 3 (S3)'s office. Interview with S3 revealed that on the morning of 09/24/2022, they reviewed the medication order and inputted it into their system to be ready to be administered on that day. LPA records review of Medication Administration Records and LPAs interview with S1 and S2 further revealed the Pantoprazole (40mg, 1 tablet daily) was located in the med cart along with the rest of R1's medications on 09/24/2022. LPA records review revealed that Pantoprazole (40mg, 1 tablet daily) was administered on 09/24/2022. Based on information gathered during this and previous visits, the department does not have sufficient evidence to prove this allegation occurred. Therefore the allegation that staff mismanaged resident's medication has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted and report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5