198320184-5-3-2024-11-AS-JHAD-D54RCH-20240509125422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 05/02/2024
Date Signed: 05/03/2024 09:16:05 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20231116093046

FACILITY NAME:	AVENIR MEMORY CARE WESTSIDE		FACILITY NUMBER:	198320184
ADMINISTRATOR:	JODI KANOWITZ		FACILITY TYPE:	740
ADDRESS:	7501 OSAGE AVE		TELEPHONE:	(424) 282-0040
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	88	CENSUS:	DATE:	05/02/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Director of sales and marketing Ashley Shire		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff dispensed medication not prescribed for the resident.

INVESTIGATION FINDINGS:

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On 05/02/24 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent visit to render investigation findings. LPA met withDirector of sales and marketing Ashley Shire and the purpose of the visit was explained.

The investigation consisted of the following: On 11/21/23 LPA Villegas conducted an initial complaint investigation visit regarding the above allegation; LPA met with Executive Director (ED) Jodi Kanowitz as the purpose of the visit was explained. On 11/21/23 LPA obtained copies of staff and resident rosters, copies of 16-hour medication training, R1's facesheet, Physicians report, needs and service plan, admission agreement, emergency I.D. form and preplacement appraisal. On 11/21/23 LPA interviewed, ED, and staff #1-6 (S1-S6). LPA was unable to interview R1 as R1 is no longer receiving care from Avenir Memory Care Westside.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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 11-AS-20231116093046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 05/02/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Staff dispensed medication not prescribed for the resident.

It is being alleged that resident’s drug test which was administered at the emergency room in the Santa Monica UCLA Medical Center returned positive for fentanyl. On 11/21/23 LPA interviewed ED regarding the allegation above, ED denied the allegation. Per ED, there are no residents with a prescription for fentanyl and there are no residents taking any substances that have not been prescribed. ED continued to report that residents do not go out into the community unless a resident is with family. On 11/21/23 LPA interviewed S1-S6, 6 of 6 staff interviewed denied the allegation and reported that only med techs dispense medication and residents have not received incorrect medications. LPA reviewed the facilities sign in/out sheet which indicted R1 was signed out by family on 11/14/23 and according to medical records R1 was taken to Santa Monica UCLA Medical Center ER on 11/14/23. LPA conducted a review of medication administration records of all residents; no resident has a prescription for fentanyl. CCLD reviewed medical records obtained from the Santa Monica UCLA Medical Center and revealed the resident was taking multiple medications at Avenir Memory Care Westside for her medical conditions which were: Carbidopa-levodopa, Mirtazapine, Rivastigmine, and Sertraline. While in the ED on 11/14/23, labs and tests were ordered to see if the resident’s symptoms were from ingestion of drugs, a mass or from bleeding in the brain. The urine drug screen result on 11/14/23, was positive for fentanyl. The urine drug screen result was followed with the verbiage, “…If the screen result is not consistent with the resident's medication(s), confirmation testing should be ordered for the drug(s) of interest. "There was no documented evidence confirmatory testing was done."

Based on records reviews and interviews there is insufficient evidence to determine if R1 ingested fentanyl there for the allegation is unsubstantiated.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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