197609786-9-13-2022-29-AS-JAPL-CJESDZ-20220919134758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609786
Report Date: 09/13/2022
Date Signed: 09/13/2022 04:34:01 PM

Unsubstantiated

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-NP-20220222171126

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:	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 3	DATE:	09/13/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Irina Fried and Serguei Kalistratov		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff failed to assist resident with the self-administration of medication
Staff failed to refill resident's presciptions in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit to this facility. The LPA met with staff Irina Fried and explained the reason for the visit. The Administrator Serguei Kalistratov arrived shortly thereafter.

During the initial visit conducted on 3/1/2022, LPA’s Elsie Campos and Ashley Smith interviewed a resident's responsible party at 2:44 p.m., interviewed residents at 1:45 p.m., and 1:59 p.m., and, interviewed staff at 3:12 p.m., 3:27 p.m. and 3:46 p.m. The LPA's also obtained documents pertinent to the investigation. During a subsequent visit on 8/3/2022 the LPA, interviewed staff at 3:10 p.m. and 3:18 p.m., interviewed residents at 3:30 p.m., 3:40 p.m. and 4:15 p.m., obtained additional documents at 4:28 p.m. and delivered findings on four out of six allegations. During today’s visit the LPA conducted a medication audit at 11:45 a.m. and delivered findings on two allegations.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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-NP-20220222171126

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 09/13/2022

NARRATIVE

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Regarding the allegation: Staff failed to assist resident with the self-administration of medication

It was alleged that staff, are not providing Resident #1 (R1) with all their medications. During today’s visit the LPA was unable to review the Medication Administration Record (MAR) for R1 as no records were available. Staff indicated that the MAR is not something they normally complete and only complete the Centrally Stored Medication logs. A review of the centrally stored medication log for Resident #1 (R1) revealed that R1’s medications were logged but because R1 is no longer a resident at the facility, the medications were not available for verification by the LPA. Staff interviews confirmed that the staff whom assisted R1 with the self-administration of medication always assisted R1. An interview with R1 confirmed no concerns regarding assistance with self-administration of medication. Based on the investigation, there is insufficient evidence to support the claim that the staff failed to assist resident with the self-administration of medication. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff failed to refill resident’s prescriptions in a timely manner

It was alleged that Resident #1 (R1) has not had their prescriptions refilled in a month and a half. During a collateral visit to R1’s new residence on 7/27/2022 R1 communicated that they did not recall ever going without their medications or not having their medications refilled during their stay at Woodland Hills Retirement Home. Staff interviews confirmed that R1 was never without their prescriptions. During today’s visit, the LPA reviewed R1’s Centrally Stored Medication Log and found them to be in order, however the LPA was unable to confirm as R1 no longer resides at the facility. Staff denied that R1 ever missed a medication dosage. Based on the information obtained, there is insufficient evidence to support the claim that the facility did not properly manage R1’s medications. This allegation is deemed Unsubstantiated at this time.

However, the LPA audited medications for 2 out of 3 residents and identified medication errors that were unrelated to this complaint and this will be addressed on a case management report. Exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

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