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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609542
Report Date: 03/15/2022
Date Signed: 03/16/2022 08:42:58 AM



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
10/12/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211012112342
FACILITY NAME:BLYTHE STREET ELDERLY CAREFACILITY NUMBER:
197609542
ADMINISTRATOR:OHANYAN, NONAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(323) 947-7005
CITY:N HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:5CENSUS: 4DATE:
03/15/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nona OhanyanTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Resident hospitalized for illnesses related to mismanagement of medications.
Medications administered to resident with no doctor's orders.
Resident medications not discontinued per doctor's orders.
Medication directions were changed with no doctor's order.
Resident had stage 3 pressure injury.

INVESTIGATION FINDINGS:
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Licensing Program Analyst Sandra Urena arrived unannounced to deliver the findings of the above allegation. The LPA met with Administrator Nona Ohanyan, and explained the reason for the visit.

On 10/12/2021, the Department received a complaint of neglect/lack of care and supervision, resulting in Resident #1 (R1) developing a stage three pressure injury, hospitalization and illnesses due to mismanagement of medications, and an overall failure to assist with the self-administration of medications as prescribed. Community Care Licensing Division’s Investigations Branch (IB) Investigator Peter Zertuche was assigned to the case. On 10/13/2021, LPA Salia Walker conducted the initial visit to conduct a records review and to obtain pertinent documents.

Continues on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
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 5
Control Number 29-AS-20211012112342
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
VISIT DATE: 03/15/2022
NARRATIVE
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On 12/07/2021, LPA Sandra Urena conducted a subsequent visit from 12:05 PM – 2:10 PM to conduct interviews and deliver Unsubstantiated findings to one out of six allegations. IB Investigator Zertuche interviewed collateral agency representatives on 10/19/2021 at 4:30 p.m. and 10/20/2021 at 3:30 p.m.; interviewed a family member of R1 on 10/21/2021 at 4:30 p.m.; interviewed residents on 11/16/2021 at 2:15 p.m. and 2:30 p.m.; interviewed staff on 11/16/2021 at 3:00 p.m.; interviewed R1’s primary care physician on 12/23/2021 at 5:30 p.m.; and, reviewed medical records on 10/26/2021 and 11/04/2021.

Regarding the allegation: Resident hospitalized for illnesses related to mismanagement of medications
It was alleged that R1 was hospitalized due to a mismanagement of medications. Interviews and records review revealed that at the time the complaint was received, R1 no longer resided at this facility and as a result, medications were destroyed and no longer available for the Department to conduct a proper medication audit. A review of R1’s Physician’s Report dated 4/21/2021 noted that R1 had a diagnosis of Dementia, diabetes, colon cancer, hypertension, atrial fibrillation, and R1 also had a colostomy bag. Interviews and records review revealed that R1 was hospitalized on 8/9/2021 due to unusual weakness. R1 was admitted to the hospital with a diagnosis of a right stroke with mild hemorrhage and chronic strokes in the left frontal lobe. In addition, R1 had severe stiffness, which was expected to be medication induced parkinsonism. An interview with R1’s primary care physician knowledgeable of R1’s medical condition denied claims that R1 was hospitalized due to a mismanagement of medications. It was further suggested that R1 had multiple co-morbidities that contributed to R1’s decline. As such, it was communicated R1’s medically induced parkinsonism would not have been a result of medications administered in the facility, as R1 was not taking any psychotic medications; yet, the issue may have been with the medications administered in the hospital due to R1’s stroke. Based on the investigation, there is insufficient evidence to support the claim that R1 was hospitalized for illnesses related to a mismanagement of medication. It was further noted that it was not believed that facility neglect resulted in R1 becoming hospitalized. This allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20211012112342
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
VISIT DATE: 03/15/2022
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Regarding the allegation: Resident had stage 3 pressure injury.
It was alleged that R1 developed a stage three pressure injury due to neglect. Records review indicated a stage II pressure injury on 06/09/2021, with notes stating a formal home health order would be completed and in effect 6/14/2021. Yet records revealed that the home health care began on 07/07/2021. It was further documented that weekly wound care monitoring was to be conducted by home health, and that the facility administrator – whom was an appropriately skilled professional – would perform daily wound care otherwise. Information obtained from staff interviews negated claims that R1 had a stage III pressure injury while in the facility, and noted that home health was caring for the wound. Prior to hospitalization, it was alleged that the wound was staged at a stage II. Facility staff claimed that R1 was regularly repositioned and wound care was provided. Records review demonstrated that upon being hospitalized on 8/9/2021, R1 was found to have a stage III pressure injury on the sacral and right elbow. Further review notated that R1’s wounds were staged and photographed on 08/10/2021. However, there is insufficient evidence to support the allegation that the stage III wound developed in the facility, as the home health nursing observing R1’s wound did not stage it above a stage II, and the wound had been stabilized as a stage II wound a month prior to R1 being hospitalized. Based on the availability of evidence, there is insufficient evidence to support the claim that due to facility neglect, R1 developed a stage III pressure injury while residing in the facility. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Medications administered to resident with no doctor's orders.
It was alleged that Risperidone was administered to R1 on 4/23/2021, yet it was not ordered until 05/20/2021. Staff interviews and interviews with R1’s primary care physician negated claims that R1 could have received Risperidone prior to 05/20/2021, as the medication would only be provided by R1’s primary pharmacy, and staff denied claims that they had the medication in their possession to assist the resident with the self-administration of the medication on 4/23/2021. R1’s primary care physician claimed that there were two orders for Risperidone – 5/20/2021 – 6/17/2021, and 6/16/2021 – 6/22/2021. It is believed that the Risperidone was documented on the facility Medication Administration Record (MAR) in error, and at the time of the complaint initiation, R1’s medications had been destroyed and no additional supporting documents could be provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20211012112342
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
VISIT DATE: 03/15/2022
NARRATIVE
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 A review of the medication list from when R1 was admitted to this facility from a skilled nursing facility on 4/23/2021 did not reveal that Risperidone was listed as one of R1’s medications. Deficiencies observed related to medication-related errors were cited on separate Case Management-Deficiencies report on 10/13/2021. Based on the availability of evidence, there is insufficient evidence to support the claim that medications were administered to R1 without a doctor’s order prior to 5/20/2021. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident medications not discontinued per doctor's orders.
It was alleged that the medication Digoxin prescribed on 6/11/2021 should have been discontinued but it was not, resulting in R1 being Digoxin toxic when admitted to the hospital on 8/9/2021. A review of the facility’s MARs revealed that the Digoxin was documented on the April MAR as being administered from 4/23/2021 – 4/30/2021, but further documentation regarding the administration of Digoxin could not be produced. According to R1’s primary care physician, they observed an order for Digoxin from 4/23/2021 and discontinued on 5/12/2021. As such, the primary care physician believed that the medication was discontinued. Lastly, it was communicated that the initial dosage prescribed to R1 was very minimal and should not have been toxic unless it was administered in the hospital. Hospital records indicated that Digoxin was ordered at the hospital on 8/10/2021 and at that time, Digoxin levels were below 0.2, but increased to 3.5 on 08/16/2021, resulting in the discontinuation of the medication. Based on the information available during the investigation, there is insufficient evidence to support the claim that staff failed to discontinue R1’s medications. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Medication directions were changed with no doctor's order.
It was alleged that facility staff failed to administer R1’s blood pressure medication as prescribed, as R1 did not receive it daily as prescribed. A review of the facility’s MAR demonstrated that the blood pressure medication was self-administered as prescribed. However, interviews with the Administrator revealed that they did not provide the medication if R1’s blood pressure reading was too low. However, there was no blood pressure log to indicate said blood pressure readings.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20211012112342
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
VISIT DATE: 03/15/2022
NARRATIVE
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 R1’s primary care physician supported claims that if R1’s blood pressure medication was too low, then the facility should not have assisted with the self-administration of the medication. Only an appropriately skilled professional may make the determination whether or not to give the medication based on the blood pressure readings, and fortunately, the administrator is an appropriately skilled professional. Deficiencies observed related to medication-related errors were cited on separate Case Management-Deficiencies report on 10/13/2021. Based on the information obtained, there is insufficient evidence to support the claim that medication directions were changed with no doctor's order. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted with administrator, signatures were gathered. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5