197610031-7-14-2023-29-AS-JAPL-CU736B-20230728175805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610031
Report Date: 07/13/2023
Date Signed: 07/14/2023 08:10:38 AM

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
06/20/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230620141817

FACILITY NAME:	CARMEL OAKS ASSISTED LIVING		FACILITY NUMBER:	197610031
ADMINISTRATOR:	NIRVANA GHAEMI		FACILITY TYPE:	740
ADDRESS:	4607 LENNOX AVE		TELEPHONE:	(818) 277-1948
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY:	6	CENSUS: 6	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nirvana Ghaemi		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff did not give all of residents medication to authorized representative when resident left the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Sandra Urena and Emili Peraldi conducted a subsequent visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit.

On the allegation that ‘Staff did not give all of resident’s medication to authorized representative when resident left the facility’; it is the complainant’s concern that the facility staff withheld one of the Resident’s #1(R1) medication, and as of 06/13/2023, some medications are still being order from the pharmacy and being delivered to the facility, even though the R1 left the facility some months ago. To investigate the allegation the LPAs interviewed the administrator on 06/21/2023 at 2:21 p.m., the administrator stated that all medications were given to R1’s responsible party when the resident left the facility. The administrator provided the LPAs with a letter signed by the R1’s responsible party dated 01/12/2023. The letter stated that ‘Everything is checked and there are no concerns. All belongings are with the resident’s POA’.
Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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-20230620141817

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: CARMEL OAKS ASSISTED LIVING	FACILITY NUMBER: 197610031
	VISIT DATE: 07/13/2023

NARRATIVE

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The LPA verified the authenticity of the letter with the responsible party, who stated that the letter was authentic. Additionally, the administrator stated that they had communicated with the pharmacy on 01/14/2023, and communicated with the doctor prescribing the medication to inform them that the resident not living at the facility anymore as of 01/12/2023. The administrator stated that the pharmacy did indeed refill four medications on 3/11/2023. The medications were delivered by the pharmacy and left with the facility staff in the evening hours. The administrator reviewed the medications the next morning, and discovered that the pharmacy had delivered medications for R1. The administrator stated that they communicated with the pharmacy about the medication delivered and was instructed to destroy the medications, which they did by placing all medications in water to dissolve it, then placing the medication in a can prior to disposing of it in the trashcan. The administrator provided the LPAs with the Centrally Stored Medication and Destruction Record (LIC 622) which recorded the medications delivered for R1.

Based on the information obtained through interviews and record review, there is not sufficient evidence to support the allegation that Staff did not give all of resident’s medication to the authorized representative when resident left the facility. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview was conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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