197610169-3-27-2024-31-AS-MVAO-D42VJV-20240405162921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610169
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:14:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/16/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220516115132

FACILITY NAME:	BEYOND A HOME LLC		FACILITY NUMBER:	197610169
ADMINISTRATOR:	RICHARDSON, KESHA		FACILITY TYPE:	740
ADDRESS:	6023 WEST AVE L 12		TELEPHONE:	(661) 860-5048
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	03/27/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kesha Richardson		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained pressure injuries while in care
Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 03/27/2024 Licensing Program Manager (LPM) Troy Agard and Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA and LPM met with Administrator and Licensee, Kesha Richardson. LPA explained the purpose of this visit was to gather information, conduct interviews and deliver findings for this complaint.

The investigation consisted of the following: on 05/24/2022, then, LPA Ruiz investigated and unsubstantiated six (6) of the eight (8) allegations. On 03/27/2024 from 9:45am- 10:15am LPA conducted a facility tour and interviews. LPM Agard reviewed records from 10:15am -11:01am. LPA and LPM collected R1’s Hospice records, Medication Administration Record (MAR), Needs and Services Plan, Physician Report, Staff and Resident Roster.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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 2

Control Number 31-AS-20220516115132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BEYOND A HOME LLC	FACILITY NUMBER: 197610169
	VISIT DATE: 03/27/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: Regarding the allegation: Resident sustained pressure injuries while in care. It’s being alleged a resident had a stage 2 bed sore. During interviews, LPA interviewed two (2) out of two (2) staff. S1 confirmed R1 came to the facility with a stage 2 bed sore which was being treated via hospice services. S1 denied any additional wound development. During a record review, a nursing summary from Bristol Hospice dated 02/17/2022 indicated R1 was receiving care for a stage 2 bed sore which completely healed. S2 was unable to confirm the allegation due to not knowing R1. R1 was unavailable for an interview due to passing away.

Regarding the allegation: Staff mismanaged resident's medication. It’s being alleged R1 is not receiving morphine pain medication for extreme pain. Rather, R1 was given Tylenol. During an interview with S1, they stated R1 never reported being in extreme pain, therefore Morphine was not administered. During a record review, LPA observed that extra strength Tylenol is an approved pro re nata (prn) for R1, making the facility compliant with R1’s Medication Administration Records. Interviews were attempted with all five (5) residents of which one (1) reported no issues with their medication. The other four (4) residents were unable to participate due to their cognitive function.

Based on records reviewed and interviews, both above allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2