197610449-11-21-2024-31-AS-TAGD-DBUQ58-20241211105127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610449
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:05:24 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
11/19/2024 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20241119100850

FACILITY NAME:	EXCELLENCE COMMUNITY RESIDENTIAL PROPERTIES 2		FACILITY NUMBER:	197610449
ADMINISTRATOR:	ASKEW, OCTAVIA		FACILITY TYPE:	735
ADDRESS:	4369 PORTOLA DR		TELEPHONE:	(424) 789-0439
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	4	CENSUS: 1	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Octavia Askew.		TIME COMPLETED:	09:59 AM

ALLEGATION(S):

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Facility staff left resident alone at facility
Facility staff did not dispense resident's medications as prescribed

INVESTIGATION FINDINGS:

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On 11/21/2024, Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Manager (LPM) Troy Agard initiated a complaint investigation for the allegation(s) listed above. LPA and LPM was greeted by the Licensee Octavia Askew. LPA Spaeth explained the purpose of this visit is to investigate the complaint allegation(s).

LPA Spaeth and LPM Agard interviewed the Administrator (S1) at 11:00 am until 12:00 pm. LPA Spaeth requested copies of a client’s documents. LPA received the documentation. LPA Spaeth interviewed two staff members (S2-S3) out of eight staff members at 12:00 until 12:20 pm. LPA Spaeth toured the facility and did not observe any issues.
Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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 31-AS-20241119100850

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: EXCELLENCE COMMUNITY RESIDENTIAL PROPERTIES 2	FACILITY NUMBER: 197610449
	VISIT DATE: 11/21/2024

NARRATIVE

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Regarding the allegation: Facility staff left resident alone at facility. It’s being alleged a facility staff went for a walk and left RP alone at the facility. During an interview with S1 it was determined C1 left the facility without leave (AWOL). Due to health and safety concerns, C1 was followed by S2 to ensure their safety while in the community. C1 returned back to the facility before S2. C1 locked S2 out of the facility for a short period of time but eventually letting them back in. C1 was unavailable for an interview.

Regarding the allegation: Facility staff did not dispense resident's medications as prescribed. It’s being alleged staff refused to provide clients medication as prescribed. During an interview with S1 it was determined that C1 would sometime refuse their meds or confiscate them while staff were in the process of administering them. A review of the Medication Administration Records (MAR) indicates medication was given as prescribed and on days when medication was refused by C1, it was indicated with an “x” and the initials of staff. The Woodland Hills South Regional Office received and reviewed several incident reports from the facility regarding C1’s attempts to confiscate or refuse their medication during med pass. C1 was unavailable for an interview.

Based upon staff interviews and review of the client's documentation , the allegation are unsubstantiated.

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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