197609641-3-23-2022-29-AS-DPEA-CCZSSX-20220330140840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609641
Report Date: 03/23/2022
Date Signed: 03/23/2022 03:22:32 PM

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
04/30/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210430105609

FACILITY NAME:	COMMONS AT WOODLAND HILLS, THE		FACILITY NUMBER:	197609641
ADMINISTRATOR:	STEWART, BRADLEY		FACILITY TYPE:	740
ADDRESS:	21711 VENTURA BLVD		TELEPHONE:	(818) 999-2610
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	200	CENSUS: 97	DATE:	03/23/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Hannah Meyers		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident was not given their medication in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the above allegation. Upon arrival LPA met with Executive Director Hannah Meyers and explained the reason for the visit. During the course of the investigation LPA initiated the investigation on 5/5/2021 and conducted physical plant tour and obtained copies of documents pertinent to the investigation. A subsequent visit was also conducted on 1/18/2022 to deliver findings for a separate allegation. On 3/10/2022, LPA conducted physical plant, interviewed staff and conducted a medication audit for (6) residents who reside in memory care. Today LPA reviewed pertinent documents along with Executive Director.

It was alleged that Resident 1 (R1) was not given their medication in a timely manner. LPA record review of R1's medication administration records (MARS) revealed that R1 had been administered their medications as prescribed, while R1 resided in the facility from April 1, 2021 to April 24, 2021. Further records review of nurse notes and hospital records revealed that R1 did not return to the facility after being admitted to the hospital in the early morning of 4/25/2021.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210430105609

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: COMMONS AT WOODLAND HILLS, THE	FACILITY NUMBER: 197609641
	VISIT DATE: 03/23/2022

NARRATIVE

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Continued from 9099

LPA interview with Staff further revealed that R1 was given their medications as prescribed, up until R1 was admitted to the hospital in the early morning of 4/25/2021. Interview with staff also revealed that R1 never refused medications while residing in the facility from April 1, 2021 to April 24, 2021. On 03/10/2021, LPA conducted a medication audit for (6) residents that resided in memory care. Medication audit revealed that each resident was administered their medications in a timely manner for the time period reviewed. Based on information obtained during today's and previous visits, the department does not have enough evidence to support the allegation listed above. Therefore the allegation that R1 was not given their medication in a timely manner has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

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