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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608977
Report Date: 05/21/2022
Date Signed: 05/21/2022 02:43:04 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220406152240
FACILITY NAME:THOMPSON'S GUEST HOMEFACILITY NUMBER:
197608977
ADMINISTRATOR:SAVELLA, JEFFREYFACILITY TYPE:
740
ADDRESS:22835 STRATHERN STTELEPHONE:
(818) 348-0995
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 6DATE:
05/21/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Lynn SaideTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff administered wrong medication to resident resulting in hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit. LPA spoke with administrator Jeffrey Savella by telephone and explained the reason for this visit.
It is alleged that facility staff administered the wrong medication to resident #1 (R1) resulting in R1 being hospitalized. LPA conducted the initial visit on 04/07/2022 and conducted interviews with staff and obtained pertinent information from R1’s facility file. Information obtained from an interview with facility staff revealed that on 04/04/2022 R1 was given three different medications belonging to R2 on accident by facility staff #1 (S1). After approximately ten minutes S1 realized R1 was given the wrong medications. Emergency services were called and R1 was transported to the hospital. On 04/14/2022, a request was put in at West Hills Hospital and Medical Center to obtain R1’s medical records. On 05/02/2022, R1’s medical records from West Hills Hospital and Medical Center were obtained. Upon review of R1’s medical records, it confirmed that R1 was hospitalized due to poisoning by unidentified anti-depressants and that R1 was given these anti-depressants on accident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
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 3
Control Number 31-AS-20220406152240
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: THOMPSON'S GUEST HOME
FACILITY NUMBER: 197608977
VISIT DATE: 05/21/2022
NARRATIVE
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R1 was discharged back to the facility on 04/08/2022 in good condition. Based on the information obtained through interviews and the review of R1’s medical records, this allegation is deemed substantiated at this time.

Deficiencies cited on LIC 9099 D. Appeal Rights explained. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220406152240
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: THOMPSON'S GUEST HOME
FACILITY NUMBER: 197608977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by:
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Administrator will have staff who handles medication to attend medication training from a qualified program & a qualified trainer based on H&S 1569.69. Submit signed documents from the trainer & staff of the topics trained.
Civil Penalty of 500 dollars assessed for R1 being hospitalized due to taking wrong medication.
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Based on interviews conducted and medical records reviewed R1 was given another residents medication by facility staff which posed an immediate health and safety issue for R1.
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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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3