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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609023
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:54:09 PM


Document Has Been Signed on 12/21/2022 12:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PRIMROSEFACILITY NUMBER:
197609023
ADMINISTRATOR:MUBEEN NAIMUDDINFACILITY TYPE:
740
ADDRESS:8107 DE SOTO AVETELEPHONE:
(323) 387-2755
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 4DATE:
12/21/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mubeen NaimuddinTIME COMPLETED:
12:55 PM
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An Informal Conference was conducted today at the Woodland Hills-South Adult and Senior Care Regional Office. This Informal Conference was held to discuss recent deficiencies and provide guidance to ensure future compliance.
Prior to the meeting, Licensee was given the chance to review the facility file.

Present at today's meeting were the following:
· Mubeen Naimuddin – Licensee/Administrator
· Cassandra Harris, Licensing Program Manager (LPM)
· Nicholas Reed, Licensing Program Analyst (LPA)

The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.



BRIEF HISTORY: The facility has been in operation since licensure on 12/30/2016. The Licensee also operates Primrose 2 (#197609057) since 02/01/2017 and Primrose 3 (#197609947) since 11/30/2020. Both facilities are in good standing with the Department. On 09/27/2022, an employee of Primrose mismanaged a resident’s medication which led to hospitalization and organ failure. The licensee explained that the resident had atrial fibrillation which explained their elevated heart rate and ICU admission. The resident was monitored for 3 days at the hospital. The facility was issued a deficiency and civil penalty for $500 for the hospitalization of the resident. The employee was suspended until 09/30/2022 when CCLD addressed the issue as part of a complaint investigation.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: PRIMROSE
FACILITY NUMBER: 197609023
VISIT DATE: 12/21/2022
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On 10/02/2022 the same employee committed another medication error with the same resident. The mistake was reported immediately. The resident did not require hospitalization. The resident experienced redness of the face which returned to normal condition within several hours. A deficiency and civil penalty were issued for a repeated violation within 12 months. The employee was terminated by the licensee.

The licensee tried to remedy the issue by applying for a waiver for separate pill boxes for each resident. The waiver request was denied on 10/27/2022. Licensee noted he is retraining staff at all Primrose facilities to ensure the mistake is not made again. Only 4 staff are responsible for medication assistance at the 3 facilities to reduce confusion. Blood pressure is monitored 3 times daily as well.

LPM discussed a PCC consult for the resident affected by the medication error. LPA will schedule a PCC Nurse visit to address the resident's condition.

Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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