197609763-9-12-2024-31-AS-EMIR-D9WVJF-20241010162834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609763
Report Date: 08/18/2023
Date Signed: 09/12/2024 12:21:47 PM

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:	08/18/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Eilene Krakover- Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff administered resident medication without consent
Staff leaves resident in bed for an extended period of time.
Staff left resident in soiled for an extended period of time.
Staff did not provide adequate food service to resident in care.
Facility does not have adequate staff to care for residents.
Staff did not allow resident visitors.

INVESTIGATION FINDINGS:

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This is an amended report of the prior investigation report delivered on 8/18/23. Due to new information obtained allegations findings were changed from Unsubstantiated to Substantiated. Licensing Program Analyst (LPA) Mariana Agban arrived at the facility to conduct an unannounced subsequent complaint investigation. Upon arrival, LPAs was greeted by the administrator, and the purpose of the visit was explained. Today's investigation consisted of interview with the Administrator, and obtaining additional documents.
Allegation: Staff administered resident medication without consent
It was alleged that staff administered Seroquel to R1 from April 20,2023 to April 23,2023 without consent from R1's responsible party. Records reviews and interviwes revealed that Administaor didn't notify R1's reposible party regarding R1 change of condition and the new medication prescribtion. Administrator did administer Seroquel medication on April 20, 2023 prior getting consisent from R1 responsible party. Based on information obtained the allegation is deemed Substantiated at this time.
(Conintue on 90099C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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 3

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: 08/18/2023

NARRATIVE

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Allegation: Staff leaves resident in bed for an extended period of time.
It was alleged that Staff left R1 for extended period of time in bed. Per interviews with W2 and W6 confirmed that staff left R1 for an extended period of time. Both direct witnesses confirmed that staff would only move R1 out of bed when there is a visitor in the facility or when W2 requested another staff assistance to move R1 out of the bed. W2 stated that R1 was left alone without food and no changed clothes. Administrator, didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff left resident in soiled for an extended period of time.
It was alleged that staff left R1's soiled in their diapers for an extended period of time. Interview with W2 revealed that the facility is understaffed and thus staff would use multiple diapers for one resident so staff won't change R1 as often. Although Interviews with Administrator and staff revealed that R1 would never notify them that they need to use the restroom or when they want change their diaper. R1's medical records indicated that R1 needs assistance with incontinence care. Administrator didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not provide adequate food service to resident in care.
It was alleged that staff left R1 in their dark bedroom without food. Administrator denied the allegation. However, interviews with direct witnesses confirmed that staff did not provide adequate food service to residents in care. W2 stated that R1 stayed until 11:00 AM without breakfast, and staff wouldn't offer an alternative option when R1 did not like the food. W6 noted that residents would eat only one meal daily without any snacks. W6 mentioned that staff would tell residents to wait so they could combine breakfast and lunch meals. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Facility does not have adequate staff to care for residents.
It was alleged that facility doesn't have enough staff to meet residents needs. Interviews with direct witnesses revealed that facility had 4 residents with only one staff and the Administrator. Direct witnesses confirmed that Administrator would leave the residents with one staff to run errands. W1 stated that Administrator had called for assistance to left up from the bathroom floor. W2 stated that facility has been always understaffed and the administrator was aware and didn't act on it. Based on information obtained the allegation is deemed Substantiated at this time.
(Continue on 9099C p.2)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 08/18/2023

NARRATIVE

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Allegation: Staff did not allow resident visitors.
It was alleged that Administrator did not allow visitors for R1. RP stated that on 6/21/23, Administrator asked RP via text message to not visit R1. Although, Administrator stated that her residents had visitors other day. Administrator didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time.

Exit interview conducted, citations issued on investigation report 07/22/24 and a copy of this report delivered

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

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