197609782-12-7-2023-29-AS-KLOZ-CYXPQS-20231228103137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609782
Report Date: 12/06/2023
Date Signed: 12/07/2023 08:14:43 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
11/29/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20231129131316

FACILITY NAME:	CARRIES CARE VILLA		FACILITY NUMBER:	197609782
ADMINISTRATOR:	ACOSTA, MARK RYAN		FACILITY TYPE:	740
ADDRESS:	12550 BURTON ST		TELEPHONE:	(818) 767-4503
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 4	DATE:	12/06/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Carrie Acosta		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Facility is refusing resident after hospitalization.

INVESTIGATION FINDINGS:

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Licensing program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegation listed above. The LPA arrived at 10:40 a.m. met with Administrator Carrie Acosta and explained the reason for the visit.

On 11/29/2023, the department received a complaint about the allegation listed above. The Reporting Party (RP) alleged that the facility refused to take a resident (R1) after being discharged from the hospital. The hospital called the facility to inform them that the R1 was being discharged from the hospital, and the facility needed to be aware that R1 was going back via private ambulance, however, staff refused to take R1 back in the facility.

Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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 29-AS-20231129131316

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARRIES CARE VILLA	FACILITY NUMBER: 197609782
	VISIT DATE: 12/06/2023

NARRATIVE

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To investigate the allegation the LPA interviewed the RP on 12/06/2023 at approximately 10:05 a.m. The LPA interviewed the Administrator at approximately 10:40 a.m. and the R1 at approximately 11:12 a.m. The RP stated that when they called the facility, they spoke to the administrator to let them know that R1 was being discharged from the hospital, and to inform staff about admitting R1 back to the facility. However, the RP reports that the administrator told them that they did not want R1 back at the facility, and to send R1 somewhere else. The RP explained to the administrator that per State regulations, the facility must take the resident back. The RP added that the administrator hanged up on the call, and when the RP attempted to call the administrator back the calls went to voice mail. The RP left several messages for the Administrator and after three (3) hours of phone calls, the administrator called back, and said that it was ok to send the R1 back to the facility. The administrator’s interview revealed that they had indeed said to the RP that they did not want back R1 due to R1’s physical needs, however there was no updated appraisal in R1’s file to substantiate a change in condition that required additional care at another facility. The interview with the R1 revealed that they had heard the administrator telling the RP over the phone that they did not want them back at the facility.

Based on the information obtained through interviews, the allegation that Facility is refusing resident after hospitalization, is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).

Citations were issued. Exit interview conducted. A copy of the report and Appeal Rights were issued via email.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231129131316

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARRIES CARE VILLA	FACILITY NUMBER: 197609782
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/11/2023 Section Cited CCR 87468.2(a)(20)(a)	1 2 3 4 5 6 7	87468.2 (a)(20)(a) Personal Rights of Residents ... residents in privately operated residential care facilities for ... shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for ...regulations and shall comply... For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee...and which poses an immediate health and safety or personal rights risk. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator admitted R1 same day, but three hours later after R1 was discharged from hospital. The Licensee/Administrator will submit a written explanation to the Regional Office for their actions pertaining to Resident 1 (R1).
	8 9 10 11 12 13 14	Based on the investigation and information obtained. The administrator refused resident back to facility at the time resident was discharged, which poses an immediate risk to persons 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.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

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