197609763-7-14-2023-31-AS-EMIR-D9WVJG-20241010162834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609763
Report Date: 07/11/2023
Date Signed: 07/14/2023 09:57:37 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
07/03/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230703161605

FACILITY NAME:	BLUE SKIES RANCH		FACILITY NUMBER:	197609763
ADMINISTRATOR:	KRAKOVER, EILENE		FACILITY TYPE:	740
ADDRESS:	6061 SHIRLEY AVE		TELEPHONE:	(818) 730-4182
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 2	DATE:	07/11/2023
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Eilene Krakover- Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff do not properly lock medication room

INVESTIGATION FINDINGS:

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At 10:18 AM, Licensing Program Analyst (LPA), Mariana Agban,conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with the Administrator and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:45 AM, LPA requested resident and staff roster. At approximately 11:00 AM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected per Title 22 Regulations. At 12:00 PM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. Between 11:00 AM – 12:00 PM, LPA conducted an interview with the Administrator, and one (1) staff member out of three (3).

Allegation: Staff do not properly lock medication room
(Continue LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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-20230703161605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH	FACILITY NUMBER: 197609763
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/12/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons... This requirement is not met as evidenced by	1 2 3 4 5 6 7	Administrator will contact in-service person to change the lock, and a picture of fixed door lock on 07/12/2023 by email to LPA by POC due date.
	8 9 10 11 12 13 14	Based on observations the medication door room was unlocked and accessible to residents. The Licensee did not ensure that the medication room is locked and inaccessible to residents in care. This poses an immediate health and safety hazard to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230703161605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH	FACILITY NUMBER: 197609763
	VISIT DATE: 07/11/2023

NARRATIVE

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It was alleged that Staff do not properly lock medication room. During the physical plant tour, LPA observed that medication door room is unlocked, and the room left unattended. Interview with the administrator revealed that the door lock was fixed on June 27, 2023. However, Administrator advised that will contact in service person to change the lock within 24 hours. Based on the observations and interviews, the allegation is SUBSTANTIATED at this time

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is cited and noted on LIC 9099D.

Exit interview conducted, appeal rights, and copy of the report given.

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SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC9099 (FAS) - (06/04)

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