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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800467
Report Date: 10/07/2025
Date Signed: 10/07/2025 04:44:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2025 and conducted by Evaluator Garrett Haner-Tomasko
COMPLAINT CONTROL NUMBER: 29-AS-20250911081035
FACILITY NAME:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:AUDIE SHERBERGFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:72CENSUS: 61DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Audie SherbergTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are not dispensing medication as prescribed
INVESTIGATION FINDINGS:
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At 9:30am, on 10/7/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to deliver final findings to the allegation of this complaint. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit.

On the allegation, staff are not dispensing medication as prescribed. It was alleged that facility staff failed to bring a resident their medication timely, and when the medication was later brought, the staff also left a cup of another resident’s medications in the room, which was returned to staff.
LPA record review and interviews revealed that 49 of 60 residents at the facility receive assistance with medication management from the facility staff and multiple residents who receive this assistance take the medication carbidopa-levodopa for Parkinson’s disease, including Resident #1 (R1).

(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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 29-AS-20250911081035
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN CREEK
FACILITY NUMBER: 405800467
VISIT DATE: 10/07/2025
NARRATIVE
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Staff interviews revealed the facility has a policy to provide residents with their medications as timely as possible but with a window of one hour before and one hour after the scheduled time. Staff stated it is known that medications for Parkinson’s disease should be given on time per the physician’s order to avoid worsening symptoms. The physician order for R1’s carbidopa-levodopa states it is to be administered at 2:00am, 5:00am, 7:30am, 11:30am and 3:30pm.

Interviews revealed on one occasion staff did not bring R1 their morning medications. R1 notified staff to remind them and when staff brought R1 their medications, staff also left a cup of medications in R1’s room intended for another resident. R1 returned this medication to facility staff. Other residents interviewed stated they have not had medications left in their room intended for another resident, and staff interviewed are not aware of a time medications intended for one resident were left in another resident’s room.

Interviews and record review revealed there was a day in July 2025 when R1 used their pendant to remind the medication technician on duty, Staff #1 (S1), for their carbidopa-levodopa scheduled at 5:00am. R1 went looking for S1 and found S1 sleeping on a couch outside the medication room on the second floor. After R1 woke up S1, S1 provided R1 their medications. A verbal warning given to S1 was documented by the Administrator and after additional disciplinary actions for other reasons S1’s employment was terminated by the facility.

During staff interviews one other staff member admitted they administered R1’s medication scheduled at 2:00am approximately 75 minutes after 2:00am, and an additional interview confirmed this.

Resident interviews revealed there have been times when they did not receive their medications timely and they needed to alert staff to remind them they had not received their medications at the scheduled time.

Record review revealed the facility medication technicians are not current on the required medication training per California Health and Safety Code. This was addressed during the facility annual inspection conducted by the LPA during the same visit.

(Continued on LIC9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250911081035
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN CREEK
FACILITY NUMBER: 405800467
VISIT DATE: 10/07/2025
NARRATIVE
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Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, due to staff delaying the administration of time sensitive medication with specific hours of administration scheduled by the resident’s physician.

Exit interview conducted, deficiency cited on LIC9099-D page, report signed, and report provided to the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20250911081035
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN CREEK
FACILITY NUMBER: 405800467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) A plan for incidental medical... care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered
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Administrator states they will create a policy that ensures time sensitive medications are passed in a way not to cause delay. All staff that handle medications will be trained in this policy. The policy, training and signed staff roster will be emailed to the LPA on or before 10/21/2025.
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medications as needed. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not dispense medications as prescribed delaying the administration of time sensitive medication with specific hours of administration scheduled by the resident's
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physician which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
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