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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609683
Report Date: 06/30/2022
Date Signed: 06/30/2022 06:03:37 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
06/22/2022 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220622163304
FACILITY NAME:LONE STAR BOARD & CARE TUJUNGAFACILITY NUMBER:
197609683
ADMINISTRATOR:ALEXANDER, OTISFACILITY TYPE:
735
ADDRESS:10117 TUJUNGA CANYON BLVDTELEPHONE:
(818) 875-4501
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:35CENSUS: 28DATE:
06/30/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Gio MonicoTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff did not administer medication to client as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Tuesday Cabiness, Yelena Avetisyan, along with Daniel Avila, Office of Diversion and Re-entry, from Volunteers of Ameria, conducted an complaint investigation to determine the allegation mentioned above. LPAs met with case manager Gio Monico, who was informed the reason of the visit. The following was determined:

It was alleged that staff did not administer medication to client as prescribed. On 06/23/2022 and 06/30/2022, from 12pm to 5pm, LPA T. Cabiness conducted inteviews, reviewed medication records, and obtained documentation pertaining to the complaint, regarding client #1 (C1). According to information obtained, it was revealed that C1 was not being administered medication for (3) months, beginning in the month of December 2021, January 2022 and February 2022. LPA obtained information from the pharmacy, that C1's medication's was not ordered or delivered to the facility for C1, because facility staff did not contact the appropriate representatives to ensure that C1's medication was continued and ordered. It was also revealed, that facility staff was initializing on the medication administration record (MAR) that C1 was given medication
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
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 31-AS-20220622163304
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: LONE STAR BOARD & CARE TUJUNGA
FACILITY NUMBER: 197609683
VISIT DATE: 06/30/2022
NARRATIVE
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as prescribed, when C1 was not. Case manager Gio Monico confirmed, and admitted that the facility staff signed that C1 received medication, when in fact, C1 was not given the medication. LPAs, also reviewed other client medication records, and it was observed, that client # 2 (C2) was not also not giving medication as prescribed, and staff documented that C2 was given medication. Therefore, based on record review and documentation obtained, the allegation "Staff did not administer medication to client as prescribed" is SUBSTANTIATED.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20220622163304
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: LONE STAR BOARD & CARE TUJUNGA
FACILITY NUMBER: 197609683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
HSC
80075(b)(1)(A-B)
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80075 (1)...facility staff who receive training may assist clients...o(A)...staff must receive training from a licensed professional... (B)...This requirement was nt met, evidenced by,
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Case manager AGREED to provide vendorized medication training for all staff,
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 based on record review, staff did not administer medication as prescribed. This is an immediate health and safety risk to clients in care.
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Verification of the scheduled training will be submitted by 7/1/2022 with the trainers credentials. Verification of Completed training will need to be submittd by 7/20/2022.
Type A
07/01/2022
Section Cited
CCR
80075(b)(5)(B)
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Health Related Services: Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (B) Once ordered by the physician the medication is given according to the physician's directions.
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Case manager AGREED to provide vendorized medication training for all staff, and submit updated centrally stored medication records for all clients. Provide scheduled training by by POC date.
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This requirement was not met as evidenced By: Based on records review and interview the licensee did not comply with the cited section by not ensuring C1 and C2 received medications as prescribed which poses and immediate health and safety and personal rights to clients in care.
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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: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20220622163304
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: LONE STAR BOARD & CARE TUJUNGA
FACILITY NUMBER: 197609683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
80075(k)(7)A-G
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Health Related Services: The following requirements shall apply to medications which are centrally stored: (7)The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications
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Case manager AGREED to provide vendorized medication training for all staff, and submit updated centrally stored medication records for all clients. Provide scheduled training by by POC date.
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which is retained for at least
one year and includes the following: This requirement was not met as evidenced by: Based on record review an interview the licensee/administrator did not comply with the cited section by not documenting Centrally Stored Medication and
Destruction log as required. Which poses and immediate health and safety and personal rights risk to clients in care

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Type A
07/01/2022
Section Cited
CCR
80012(a)
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False Claims: (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement
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Case manager AGREED to provide vendorized medication training for all staff, and submit updated centrally stored medication records for all clients. Provide scheduled training by by POC date.
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 evidenced by; based on facility documents, staff initialed they administered medication to clients, when they did not. This is a immediate health and safety risk to clients in care
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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: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20220622163304
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: LONE STAR BOARD & CARE TUJUNGA
FACILITY NUMBER: 197609683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
80065(a)
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(a)Facility personnel shall be competent to provide the services necessary to meet individual client needs as necessary to meet such needs. This requirement was not met as evidenced by: Based on review of
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Licensee/Administrator will designate/hire 1 staff to provide medication assistance to clients and ensure proper documentation and follow up is completed for all clients.
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records/count & interview the licensee did not comply with the cited section by not ensuring staff were competent to provide medication assistance as necessary which poses an immediate health/safety, personal rights risk to residents in care
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Name of the Designated staff, schedule of the staff, specified job duties and verification of the medication training will be submitted as POC
Type A
07/01/2022
Section Cited
CCR
80064(a)(2-7)
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The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients. the citations issued during today’s visit.
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Licensee/administrators will attend vendorized medication training related to all cited regulations. Verification of the scheduled training with the trainers.
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This requirement was not
met as evidenced by: Based on interview, records review the licensee did not comply with the cited sections as demonstrated by the information obtained during the course of the investigation and
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Credentials will be submitted by 7/1/2022 and verification of completed training will need to be
submitted by 7/20/2022.

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: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5