197609786-10-30-2024-29-AS-KHEN-DBER9C-20241127114920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609786
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:52:13 PM

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
10/29/2024 and conducted by Evaluator Angela Barutyan

COMPLAINT CONTROL NUMBER: 29-AS-20241029131721

FACILITY NAME:	WOODLAND HILLS RETIREMENT HOME		FACILITY NUMBER:	197609786
ADMINISTRATOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	24301 OXNARD ST		TELEPHONE:	(818) 564-4381
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Serguei Kalistratov		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Staff did not dispense medication as prescribed by physician

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegations listed above at 10:50AM. LPA met with staff and Licensee who arrived at 11:30AM. Entrance interview conducted.

During today's visit, LPA conducted a brief physical plant tour at 10:53AM, interviewed two (2) residents and two (2) staff and attempted interviews with two (2) other residents, conducted a medication review for three (3) residents at 11:24AM, and reviewed and obtained copies of pertinent documents.

At approximately 01:05PM, LPA discussed allegations with Licensee and Lead Caregiver.
Report Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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 29-AS-20241029131721

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 10/30/2024

NARRATIVE

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It was alleged that staff did not dispense medication as prescribed by physician. LPA conducted a medication review for three (3) residents between 11:24AM – 1:05PM. LPA observed the centrally stored medication and destruction record (CSMDR) for Resident #1 (R1) and observed three (3) medication errors. Medication counts for Melatonin 10 mg, Trazadone 50 mg, and Acetaminophen 15 mL were off and could not be accounted for. The administration instructions from the doctor’s order for the Acetaminophen stated “take 15 mLs by mouth every 6 hours Not to exceed 3000 mg Acetaminophen from all sources per 24 hours..indications: fever, pain, temp > 100F, mild pain 1-3/10.” Meanwhile, the instructions on the facility’s CSMDR stated “15 mLs every 6 hours/as needed.” The start date on the CSMDR was missing, however LPA observed a label on the bottle stating the medication was opened on 08/28/2024. Interviews with Staff #1 (S1), Lead Caregiver (LC), and Licensee Kalistratov revealed that that the Acetaminophen was not being administered every 6 hours as prescribed. LC stated that the medication was started on 08/28/2024 and was given once per day. However, the serving size is 15 mL and the bottle quantity is 473 mL, meaning that there are about 31.5 servings per bottle and therefore, the bottle would have finished around 09/28/2024 if administered as LC stated. The label also states that the medication is to be administered every 6 hours, not once per day. S1 and LC stated that R1 is asleep for most of the day and night, and they have difficulty waking the resident up for the medication, however, no documentation could be provided. S1, LC, and Licensee also stated that there were difficulties in interpreting the label since it says for pain and/or fever. S1, LC, and Licensee stated that the Acetaminophen was given routinely, however, LPA obtained evidence from credible sources revealing that the Acetaminophen was believed to be a PRN medication by the facility and is also why the medication count was off. Based on medication review, interviews, and record review, the allegation “Staff did not dispense medication as prescribed by physician” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties.

Licensee was unable to stay for the duration of the visit and designated staff Arystanbek Yeshibayev to sign the report.

Exit interview conducted. Appeal rights and a copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20241029131721

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/31/2024 Section Cited CCR 87465(h)(4)	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: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee contacted a hospice nurse to discuss medications on 10/27/2024. Licensee is an LVN and will conduct medication training to all staff and submit proof to CCL by 10/31/2024.
	8 9 10 11 12 13 14	Based on interviews and medication and record reviews, the licensee did not comply with the section cited above as 3 medications were not properly maintained which poses an immediate health, safety, and personal rights risk 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5

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
10/29/2024 and conducted by Evaluator Angela Barutyan

COMPLAINT CONTROL NUMBER: 29-AS-20241029131721

FACILITY NAME:	WOODLAND HILLS RETIREMENT HOME		FACILITY NUMBER:	197609786
ADMINISTRATOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	24301 OXNARD ST		TELEPHONE:	(818) 564-4381
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Serguei Kalistratov		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Staff did not properly maintain resident’s medical records
Staff did not ensure resident’s medical records remained confidential
Staff did not properly secure residents’ medication

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20241029131721

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 10/30/2024

NARRATIVE

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It was alleged that staff did not properly maintain resident’s medical records and that staff did not ensure resident’s medical records remained confidential. LPA observed resident records to be stored in locked cabinets in the kitchen. LPA reviewed resident records and observed records to be in order and compliance with regulation. LPA interviewed the Lead Caregiver (LC) who stated that resident records are confidential and only staff have the key to unlock the cabinet containing the files. LPA did not observe any records stored in a way that compromises confidentiality.

It was further alleged that staff did not properly secure residents’ medication. LPA observed a locked medication cabinet in the locked garage. The cabinet was transparent, and medications could be observed without unlocking the cabinet. Staff stated that the cabinet was originally centrally stored in the kitchen and was moved to the garage on 10/26/2024. Per regulation, medications shall be stored inaccessible, and the medications stored in the transparent medication cabinet are inaccessible as they are kept locked. Although the cabinet is transparent, residents and other parties are unable to access the medications. Based on observation, interviews, and record review, the Department does not have sufficient evidence to corroborate the allegations. Although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that violations occurred, therefore, the allegations “Staff did not properly maintain resident’s medical records,” “Staff did not ensure resident’s medical records remained confidential,” and “Staff did not properly secure residents’ medication”” are deemed UNSUBSTANTIATED at this time.

Licensee was unable to stay for the duration of the visit and designated staff Arystanbek Yeshibayev to sign the report.

Exit interview conducted. Copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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