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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610040
Report Date: 02/08/2024
Date Signed: 04/12/2024 09:01:41 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/29/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240129123614
FACILITY NAME:MONTARE AT THE CANYON 2FACILITY NUMBER:
197610040
ADMINISTRATOR:ALEXANDRA DECLEENEFACILITY TYPE:
772
ADDRESS:2890 KANAN DUME RDTELEPHONE:
(203) 823-8588
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY:10CENSUS: 0DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Katarina Boshoff- VP DevelopmentTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not properly manage medications stored at the facility.
INVESTIGATION FINDINGS:
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This is an Amendment to the original report issued 02/08/2024. Additional information was added to clarify the investigation

At 9:45am, Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Angela Panushkina conducted a subsequent complaint visit to deliver the finding of the above allegation. LPAs met with the Cheif Operating Officer (COO), Denise Ojarigi, and a Director of Nursing (DON), Faridah Gonzalez and explained the reason for the visit.

On 01-29-2024 LPA Ngo-Castaneda conducted an initial 10-day visit. On that day LPA toured the home, conducted interviews, collected and reviewed records. During the initial visit LPA observed the medication room and the medication cabinet/cart was kept locked and inaccessible to clients in care. However, through the video footage provided by DON regarding the incident that occurred on 01/24/24, LPA observed C1 had a full access to the facility medication room through the sliding door. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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 3
Control Number 31-AS-20240129123614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONTARE AT THE CANYON 2
FACILITY NUMBER: 197610040
VISIT DATE: 02/08/2024
NARRATIVE
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Also, through the video footage, LPA observed the facility did not properly store medications in a medication cart/cabinet, and it was kept unlocked and accessible to clients in care.

The incident occurred on 1/24/2024 approximately 2:25 AM, when C1 was able to gain access to the medication room that was left unlocked. Once C1 gained access to the room, C1 was able to ingest medications such as: Keppra, Depakote, and Gabapentin that resulted C1 to be transferred to ICU at Los Robles Hospital.

During today’s visit, LPAs Ngo-Castaneda and Panushkina conducted an interview with COO and DON and both parties also confirmed that during the video footage, dated on 01/24/24, they observed that S2 left the shift without locking the medication cabinet and or checking to see if the sliding door in a Medication Room was kept locked.

LPAs were also provided with a copy of a video footage and confirmed the medication cabinet and the sliding door to the Medication Room were not locked and remained accessible to clients in care. At 12:20pm, LPA Panushkina contacted S2 and was informed that the facility had no policy of locking the medication cabinet until the incident occurred on 01/24/24. S2 also informed LPA that during the shift changes no one was told to confirm if the sliding door to the medication room was kept locked. In addition, at 12:30pm, LPA contacted S3 and S3 confirmed the fact that the facility had no policy of locking the medication cart/cabinet and or checking if the sliding door is locked during their shift changes. However, LPAs conducted review of Medication Policy and observed that “All medication shall be stored in locking cabinets or carts.”

This is an immediate health and safety risk to clients in care. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED.

Deficiency cited on LIC 9099 D.

Appeal Rights explained. Exit Interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240129123614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONTARE AT THE CANYON 2
FACILITY NUMBER: 197610040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
81072(a)(2)
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Each client shall have personal rights which include, but are not limited to, the following:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
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LPAs received proof of updated training conducted on 02/06/24. On 01/31/24 two (2) Supervisors were terminated due to not following the Medication Policy and Procedures.
Deficiency cleared during todays visit
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 Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to keep medication room locked and inaccessible to clients, which poses an immediate health and safety risk to clients in care.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
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