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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801723
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:10:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
09/03/2024 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20240903160815
FACILITY NAME:PRIMROSEFACILITY NUMBER:
425801723
ADMINISTRATOR:DOROTHY BERGERFACILITY TYPE:
740
ADDRESS:4630 SONG LANETELEPHONE:
(805) 310-6996
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 14DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dorothy Berger, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff mismanged resident's medication
Facility staff did not appropriately communicate a change of condition
INVESTIGATION FINDINGS:
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On 09/26/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Dorothy Berger and explained the reason for the visit.

On the allegation: Facility Staff mismanaged resident’s medication. It is alleged that there are multiple incidents in which Resident #1 (R1) had medication errors caused by facility staff. These incidents allegedly occurred on 08/19/2024, 08/20/2024, 09/16/2024, and 09/20/2024. The allegation states the medication errors by staff consisted of medication being given at incorrect doses to R1 at the wrong time of day, staff losing portions of medication tablets that were supposed to be dispensed to R1, and staff not checking that R1’s responsible party had been given the correct medications prior to R1 having an outing from the facility.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 5
Control Number 29-AS-20240903160815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE
FACILITY NUMBER: 425801723
VISIT DATE: 09/26/2024
NARRATIVE
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On 08/27/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding Resident #1 (R1) alleging that on 08/19/2024, the administrator of the facility accidentally placed the 8:00am medication for R1 in the 12:00pm dispensing cup, and the 12:00pm medication for R1 in the 8:00am dispensing cup. Facility staff noticed the mistake during the passing of medications at 11:45am and called the primary care physician of R1 but received no answer. Staff additionally called the responsible party for R1. The vitals of R1 were checked and they were placed on 15-minute charting. The UIR stated R1 was orientated, no altered state, no signs of distress, no complaints of dizziness, discomfort, or pain. On 08/28/2024, the Department received a self-reported UIR regarding R1 alleging that on 08/20/2024, facility staff poured/administered medication for R1 out of a bubble pack and a portion of the medication had broken apart while being popped out of the pack.

On 09/10/2024, LPA conducted an initial complaint investigation visit to the facility. LPA requested and received relevant documentation from the facility pertinent to the allegations and interviewed Staff about the incidents involving R1. LPA received Addendums to both the 08/19/2024 and 08/20/2024 UIRs regarding medication errors for R1. The addendums provided additional details of the errors by the administrator on 08/19/2024, and the facility MedTech on 08/20/2024. Staff interviewed by LPA stated that on 08/20/2024, they were distracted by another resident at the door to the medication room when they popped the pill out of the bubble pack. When staff popped the individual pill into the cup meant for dispensing medication to R1, they did not realize that all of the pill had not been popped. Staff stated there had been a call to the facility by responsible party of R1 to state not all of the pill had been dispensed. Staff then checked the medication room and found the missing piece of the pill that had broken off when popped out of the bubble pack. Staff stated R1 was getting picked up early that day (8/20/2024) so they communicated with other staff and gave R1's medications to R1' responsible party for release while R1 was out of the facility. The medications for release were placed in a sealed envelope, the envelope was labeled by Staff and R1's responsible party.
On 09/24/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding resident #1 (R1) alleging that they had a medication error on 09/16/2024, caused by facility staff. The UIR noted that on 09/16/2024, at approximately 6:30am, facility Staff poured the 8am, 12pm, and 2pm medication for R1. Facility staff stated that the 12pm medication for R1 was pre-cut from 09/15/2024, as R1 is prescribed 5mg per dose and the medication received from the pharmacy arrives to the facility as a 10mg pill. Staff stated that the 12pm medication may not have been precisely divided in half as there appeared to be bits of broken/crumbled pill. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240903160815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE
FACILITY NUMBER: 425801723
VISIT DATE: 09/26/2024
NARRATIVE
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To prevent this from occurring again, the facility requested and received 5mg size medication pills from the pharmacy that no longer need to be cut at the facility for R1. On 09/24/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding resident #1 (R1) alleging that they had a medication error on 09/21/2024, caused by facility staff. The UIR noted that on 09/21/2024, facility staff did not give R1 their 12pm medication as staff did not see the medication in the Medication Administration Record (MAR). Staff did see the 12pm medication for R1 in a dispensing cup in the facility medication room. However, staff was confused and thought it might be prior medication from a previous dispensing to R1. Staff did not realize this mistake until the next day on 09/22/2024, and the blood pressure of R1 was not checked at 12pm for R1. Staff was counseled on safe medication preparation and medication training was conducted. The facility/Licensee policies and procedures on resident medications were reviewed.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.

On the allegation: Facility staff did not appropriately communicate a change of condition. It is alleged the blood pressure of R1 at 11:30am on 08/19/2024 constituted an overdose as blood pressure medication was the missed medication for R1 in the 08/19/2024 missed medication incident. It is alleged that the facility did not appropriately report a change in condition of R1 to their Primary Care Physician at the time of the missed medication incident on 08/19/2024. The allegation states that in the UIR provided to the Department, the facility stated that they had spoken to the Reporting Party (RP) prior to providing R1 an electrolyte drink. However, allegedly RP was not spoken with by the facility prior to providing R1 with the electrolyte drink.

Based on staff interviews and record review conducted by LPA on 09/10/2024, when the medication error regarding R1 on 08/19/2024 was discovered by the facility, staff attempted to communicate a change of condition in R1 to their Primary Care Physician (PCP). However, the PCP for R1 was at lunch and unable to speak to facility at the time of the medication error. The facility called the PCP by telephone but did not leave a voice mail message at the Doctor's office so there were no calls documented and the doctor's office did not know anything was wrong. On 09/10/2024, LPA received self-reported Addendum UIRs for the 08/19/2024 and 08/20/2024 medication incidents involving R1. The 08/19/2024 addendum included information that at 1:26pm, facility staff gave R1 an electrolyte drink prior to speaking with the responsible party of R1. However, at 1:36pm, the administrator spoke with the responsible party of R1 who advised the administrator to give R1 an electrolyte drink. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240903160815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE
FACILITY NUMBER: 425801723
VISIT DATE: 09/26/2024
NARRATIVE
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At the time of the phone call at 1:36pm, the facility administrator was not aware that facility staff had already given R1 an electrolyte drink at 1:26pm. Regarding the 08/19/2024 incident involving the blood pressure medication of R1, the facility attempted to contact the responsible party of R1 by telephone within half an hour of the facility realizing the medication mistake but received no answer. The facility was able to speak with the responsible party of R1 within an hour and a half of the realization of the medication mistake and communicated what had happened. A family member of R1 physically visited the facility two and a half hours after the realization of the medication incident and stayed at the facility for two hours. R1 was reported to be oriented, no altered state, no signs of distress, no complaints of dizziness, discomfort, or pain. The facility documented all significant occurrences that may result in changes in the resident’s physical, mental and/or functional capabilities and immediately attempted to report these changes to the resident’s physician and authorized representative.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.

Exit interview conducted. Copy of this report provided to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240903160815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PRIMROSE
FACILITY NUMBER: 425801723
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87468.2(a)(4)
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Addt'l Personal Rights Residents...(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, services that meet individual needs…delivered by staff sufficient in numbers, qualifications, competency…
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Licensee will provide all Staff with a training on Resident Personal Rights and medication training to assist residents with medical attention. Licensee has changed medication with pharmacy and trained Staff in policies/procedures.
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This requirement is not met based on interviews and records review, licensee did not comply with the section cited above when Staff caused multiple medication errors for Resident #1, which posed an immediate health and safety risk to residents in care.
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Type B
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Section Cited
CCR
87468.1(a)(8)
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Personal Rights...(a) Residents in RCFE shall have all of the following personal rights: (8) To have...representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs
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This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to report an incident and change of condition to a resident’s physician, which posed a potential health and safety risk to residents in care.
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Licensee will provide all Staff with Personal Rights training regarding residents in care at the facility. Training will include personal rights training for all deficiencies cited, including the informing of responsible parties when a resident has a change in condition.
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: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5