197609683-8-12-2023-31-AS-TAGD-CWAVKV-20231004163058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609683
Report Date: 08/12/2023
Date Signed: 08/12/2023 02:57:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
02/21/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230221135015

FACILITY NAME:	LONE STAR BOARD & CARE TUJUNGA		FACILITY NUMBER:	197609683
ADMINISTRATOR:	ALEXANDER, OTIS		FACILITY TYPE:	735
ADDRESS:	10117 TUJUNGA CANYON BLVD		TELEPHONE:	(818) 875-4501
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	35	CENSUS: 34	DATE:	08/12/2023
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Gio Monico - Assistant Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff records are incomplete
Facility does not have sufficient staff
Staff does not follow reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Assistant Administrator Gio Monico and explained the reason for the visit.

LPA conducted physical plant tour at 9:12 AM, requested copies of facility documents relevant to the investigation at 9:44 AM, interviewed residents and staff between 10:00 AM to 1:00 PM and reviewed records between 1:00 PM to 2:15 PM.

Regarding the allegation that the staff records are incomplete, it was alleged that staff records did not LPA's records review on 03/01/23 at 1:00 PM revealed that eleven (11) out of eleven (11) staff files record reviewed were complete and updated. LPA's record review today between 1:00 PM to 2:15 PM for additional staff not reviewed on prior visit, seven (7) out of seven (7) staff records reviewed were observed to be complete and updated. (continued on LIC 9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023

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 31-AS-20230221135015

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LONE STAR BOARD & CARE TUJUNGA	FACILITY NUMBER: 197609683
	VISIT DATE: 08/12/2023

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Facility does not have sufficient staff, it was alleged that the facility lack staff to care for the residents. LPA's interview with assistant administrator on 03/01/23 at around 11:30 AM revealed that the facility had no resident that need assistance with any Activity of Daily Living (ADL). LPA's observation during visits on 03/01/23, 06/08/23 and today confirmed that no resident seem to have any need for assistance on their ADLs. LPA's interview with five (5) residents or more than 10% of current census on 06/08/23 between 1:10 PM to 3:00 PM revealed that the all five (5) residents interviewed believe that they were independent and there is sufficient staff at the facility. LPA's interview today between 10:00 AM to 1:00 PM with additional six (6) residents or more than 15% of the current census also stated that all six (6) of them were independent and there is sufficient staff at the facility.

Regarding the allegation that Staff does not follow reporting requirements, it was alleged that two (2) residents passed away at the facility and were not reported to the provider Agency. LPA's record review today between 1:00 PM and 2:15 PM revealed that the two (2) residents who passed away were not residents of this facility but that of a sister facility located outside of the jurisdiction of the Woodland Hills South Adult and Senior Care Regional Office (WHSASCRO). Further review also revealed that the facility is regularly submitting Unusual Incident Report (LIC 624) and Death Report (LIC 624A) to CCL within the time frame after occurrence.

Based on the information gathered during this and prior visits, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023

LIC9099 (FAS) - (06/04)

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