198601566-11-5-2021-11-AS-AJKK-C9U5CJ-20211218185025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 10/06/2021
Date Signed: 11/05/2021 11:35:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/23/2021 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20210823133710

FACILITY NAME:	STUDIO ROYALE		FACILITY NUMBER:	198601566
ADMINISTRATOR:	TERRI WEITZMAN		FACILITY TYPE:	740
ADDRESS:	3975 OVERLAND AVENUE		TELEPHONE:	(310) 836-5854
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	175	CENSUS: 87	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Terri Weitzman		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident suffered a stroke from not receiving medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, October 06, 2021. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Executive Director (ED) Terri Weitzman. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: During the course of the investigation interviews were conducted with two (2) staff (S1-S2) and seven (7) residents (R2-R8). LPA Bunker requested and reviewed the resident's records. On 09/01/2021, ED Ms. Weitzman and LPA Bunker toured the medication room, observed the resident’s medication and MARs. Administration records, documentation, and observation of R1 records observed indicated the facility Med Techs failed to administer R1's medications correctly.

See continued LIC9099-C on page 2

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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 3

Control Number 11-AS-20210823133710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/06/2021 Section Cited CCR 87465(c)(1)(2)(3)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (c) (1) Once ordered by the physician the medication is given according to the physician's directions. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.	1 2 3 4 5 6 7	Deficiency corrected prior to today's complaint visit.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by:Medication records were observed. R1 did not receive Pradaxa medications as prescribed by her physician on 12/13/2021-12/15/2021This violation poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	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: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210823133710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
	VISIT DATE: 10/06/2021

NARRATIVE

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Continued LIC9099-C page #2

R1 medications were not dispensed according to the resident’s physician's directions. R1 did not receive her correct dosage of medications.

LPA Bunker requested pertinent documentation regarding the above allegation. (Physician's Report, Medical Administration Record, Admission agreement, Appraisal/Needs and Services Plan, Personnel Report, Resident's Roster, Special Incident Report, and Ongoing Medication Training)

Allegation: Resident suffered a stroke from not receiving medications as prescribed. Interviews were conducted with S1-S2 and R1-R8. The Residents interviewed stated they were happy and had no problems at the facility and the Med Techs always dispense their medications according to their physician's directions. Staff stated this was a very busy time for the facility they were also dealing with the COVID-19 Pandemic outbreak. Staff stated R1 was a new resident they hadn't got her in their input MARS. They were waiting for her primary care doctor to send the order to CVS. R1 physicians weren't answering the telephone. They kept leaving messages with the receptionist because the doctor wasn't responding or returning their calls. Staff stated R1 missed one day of her Pradaxa medication on 12/13/2020. Staff stated on 12/16/2020 @ 9:30 P.M., the caregivers Imelda Nethercott and Christian Julia said it looked like R1 was having a stroke. The Medication Aide Katerina Williams immediately called 911, R1 was transported to UCLA Westwood. Executive Director Terri Weitzman stated she self-reported the incident to R1's family members and all the appropriate agencies in a timely manner within Title 22 Regulations required time frame. On 12/17/2020 R1's son who is a doctor had the prescription order filled for Pradaxa. Ms. Weitzman stated she waited at CVS pharmacy in Marina Del Rey, CA for the order and she pick up the medication for R1. Staff agrees R1 medication was not given according to her physician's directions.

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Appeal rights were discussed, and copies of LIC9099, LIC9099-C, and LIC9099-D was provided to the
Executive Director (ED) Terri Weitzman.
Exit interview conducted.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

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