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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 06/28/2024
Date Signed: 06/28/2024 02:45:22 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
06/20/2024 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20240620150023
FACILITY NAME:LEISURE GROVE, LLCFACILITY NUMBER:
197610442
ADMINISTRATOR:MAYA MNOYANFACILITY TYPE:
740
ADDRESS:413 E. CYPRESS STREETTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 143DATE:
06/28/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Brandy RangelTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
Staff did not meet resident's medical needs
INVESTIGATION FINDINGS:
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At 9:45 a.m. on 06/28/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the assistant administrator and disclosed the reason for the visit.

To investigate the allegations above, LPA toured the facility at 10:00 a.m., interviewed four (04) staff between 10:10 a.m. and 11:45 a.m., Resident #1 (R1) at 1:45 p.m., and conducted a records review of pertinent records including but not limited to admission agreements, medical assessments, and medications records at 12:00 p.m.

Regarding the allegation “Staff mismanaged resident's medication” it was alleged that the medication Ethambutol was given at too high of a dose to R1. Also, Medication Administration Records (MARs) had missing entries which may have indicated the medications were not given at all.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
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-20240620150023
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: LEISURE GROVE, LLC
FACILITY NUMBER: 197610442
VISIT DATE: 06/28/2024
NARRATIVE
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Interview with the assistant administrator today at 11:00 a.m. revealed R1 received all medications at the proper times and dosages. The facility had poor internet connection, so they had purchased a new router. Interview with Staff #1 (S1) at 11:15 a.m. today revealed the facility followed the physician’s orders prescribed by R1’s primary physician. When the facility received information that the dosage may be incorrect, S1 contacted R1’s physician who wrote a new order for a lower dosage. The facility assisted R1 with the updated, lower dosage immediately and documented the change in their files. Interview with Staff #2 (S2) at 11:30 a.m. today revealed they properly assisted R1 with Ethambutol at the correct times and dosages that their physician prescribed. S2 documented all medications in a hand-written MAR. LPA reviewed the electronic MAR, a hand-written MAR, and the new physician order at 12:00 p.m. today. The electronic MAR showed some missing entries. The hand-written MAR showed all entries were complete. The new physician order from 06/18/24 showed a change of Ethambutol from 1,000 mg to 800 mg. LPA conducted a medication review at 1:15 p.m. today of R1’s medication Ethambutol and found all medication quantities matched the MAR. The previous container for Ethambutol 1,000 mg was destroyed and documented in the facility record. Interview with R1 at 1:45 p.m. today revealed they received all of their medications properly and felt no pain or side effects. Based on interviews and record review the facility followed all physician orders and properly assisted R1 with their medication. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff did not meet resident's medical needs” it was alleged the facility did not assist R1 with their required lab work. Interview with the assistant administrator and S1 revealed R1 had refused their previously scheduled lab work on 06/18/24. S1 arranged for another appointment on 06/21/24 which was completed. The facility received the results of the lab work on 06/24/24 around 11:00 a.m. S1 stated R1’s lab work looked good and R1 had no pain. Record review revealed R1’s lab work indicated no concerns. Interview with R1 confirmed they refused to go their initial appointment then agreed to a subsequent appointment. Based on interviews and record review the facility arranged for R1’s medical appointment and met their medical needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety risks were observed during today's visit.


Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2