198320184-5-19-2023-11-AS-MVAO-CVTM6B-20230919091937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 05/19/2023
Date Signed: 05/19/2023 08:32:51 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220916154424

FACILITY NAME:	AVENIR MEMORY CARE WESTSIDE		FACILITY NUMBER:	198320184
ADMINISTRATOR:	DRINKHOUSE-QUINTA, MARISSA		FACILITY TYPE:	740
ADDRESS:	7501 OSAGE AVE		TELEPHONE:	(424) 282-0040
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	88	CENSUS: 35	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Jodi Kanowitz		TIME COMPLETED:	03:31 PM

ALLEGATION(S):

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Staff do not dispense medications as prescribed.

INVESTIGATION FINDINGS:

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On 05/19/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility to deliver a complaint finding. LPA spoke with Executive Director Jodi Kanowitz who assisted LPA with the visit.

The investigation consisted of the following: On 9/26/2022, LPA Montoya toured the facility. LPA interviewed four (4) residents and four (4) staff. LPA’s attempt to interview two residents was unsuccessful. LPA obtained copies of staff roster, resident roster and Resident #1's service records which includes Admission Agreement, Physician's Report, Appraisals, and Medication Administration Records.

Report continued in LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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 4

Control Number 11-AS-20220916154424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 05/19/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff do not dispense medications as prescribed.

It is alleged that staff do not dispense medications as prescribed. RP stated that R1 does not get all the medications as prescribed daily. Based on records review, Resident #1 was admitted to this licensed residential care facility. The admission agreement was signed by R1’s responsible party on 3/5/2022. Per R1’s physician’s report dated 9/27/2021, R1 is not able to store and administer own prescription and PRN medications. Preplacement Appraisal dated 3/5/2023 indicates R1 is not able to manage own medications. The department conducted interviews with staff and residents. Residents (R1-R2) refused the interview while residents (R3-R6) were not able to maintain a proper conversation. Interviews with staff reveals, S1 denied the allegation that staff are not dispensing medications as prescribed. However, S1 stated the Medication Administration Record System (MAR) was not working intermittently since S1 started working in this facility on September 19, 2022. S1 admitted that S1 has no knowledge of how staff record the dispensation of R1’s medications. S2 stated that the facility’s MAR system has been down and has not been working for three weeks. S3 stated the facility has not been recording any medication dispensation on the MAR system since August of 2022. S4 stated that morning staff dispense medications as prescribed but S4 doubts the accuracy of work of the evening staff. On 9/26/2023, the department requested copies of R1’s Medication Administration Records (MARs) for three months (June 2022, July 2022 and August 2022). The facility staff provided the department copies of the Regal Specialty Pharmacy (RSP) which only show a list of medications and had no records of dispensation of R1’s medications. On 5/15/2023, the department received another form of MARs from the facility. S5 explained the Regal Specialty Pharmacy (RSP) form is only a list R1’s medications and the MedRight Administrative Web Portal is the Medication Administration Records (MAR) and these two records should show the same medications for R1. S5 stated that missed medications are explained on the MedRight form. Based on the department’s records review and interviews, some of R1’s medications listed on the RSP are not listed on MedRight; R1 had missed doses of medications and there are no explanations on MedRight for the missed doses. Based on gathered information, there is sufficient evidence to prove that staff do not dispense medications as prescribed.

Report continued in LIC 9099C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220916154424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2023 Section Cited CCR 87465(d)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication... staff designated by the licensee, shall be permitted to assist the resident with self-administration...(2) The date and time of each contact with the physician, and the physician's directions...	1 2 3 4 5 6 7	Administrator shall review Section 87465 of Title 22 and shall self-certify understanding and compliance to this regulation. Administrator shall conduct an in-service training to staff involved in dispensing medications.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observations, records review and interviews, staff failed to dispense medications as prescribed. R1 had missed doses of medications as prescribed and there are no explanations for the missed doses. This poses a potential health, safety, and/or personal rights risk to residents in care.	8 9 10 11 12 13 14	Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov. by the POC due date 06/02/23.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220916154424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 05/19/2023

NARRATIVE

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Based on the Department's observation and interviews, records review, the preponderance of evidence standard has been met, therefore the allegation, "Staff do not dispense medications as prescribed " is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Jodie Kanowitz and reports are provided along with appeal rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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