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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 08/05/2025
Date Signed: 08/05/2025 12:04:50 PM

Unsubstantiated


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
07/17/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20250717121638
FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Sanjuana EnriquezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not prevent a resident from sustaining multiple falls.
Staff administered a medication that was not prescribed to a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Wellness Director and Administrator and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/21/2025 from 11:44 am to 2:30pm, where LPA conducted interviews with administrator, staff, wellness director, and obtained relevant documents.

Interviews with reporting party were conducted on 7/21/25, pictures of Resident 1 [R1] following incidents were provided. Additional documentation was requested from the facility on 7/25/25 and provided to the LPA by the facility on 7/25/25 and 7/28/25. Interviews with the Nurse Practitioner (NP) were done on 7/25/25 at 3:20 pm. Tour of R1’s room was done on initial visit on 7/21/25. Continue on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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 3
Control Number 29-AS-20250717121638
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: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025
VISIT DATE: 08/05/2025
NARRATIVE
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On the allegation: Staff did not prevent a resident from sustaining multiple falls.
It was alleged that R1 had a fall on 06/27/25 in which R1 hurt their knee, alleged that within twelve hours of the first fall the resident got up to use the bathroom and fell and hit [their] head and was transported to the hospital. Reporting party stated that R1 lost 2 pints of blood. Records indicate there were 3 incidents, all unwitnessed, all occurred in residents’ room within a 24-hour timeframe, 2 on 6/27/25 and 1 on 6/28/25.

On 6/27/25 R1 was found at approximately 7:00 am by medication aid during medication pass, R1 was on the floor in their room. Records state and staff interviews confirmed staff assessed R1 for injuries, initially R1 verbalized no pain or injury, staff got R1 off the floor and immediately observed R1 limping and facility contacted 911, per interview with Wellness Director (WD) first responders assessed R1 and spoke with R1 and R1’s family member (F1). Medical transport was refused after the conversation, and additional medical treatment was not sought by the request of R1 and F1. Records show that at 9:55 am R1 was given a prescription PRN Tramadol for pain. Facility records show NP was notified of incident at 1:06 pm via fax. Facility submitted an incident report to Community Care Licensing (CCL).

On 6/27/25 at approximately 1:45 pm staff heard R1 yelling for help, R1 told staff and records state that R1 was trying to open their door and fell. Physical Therapy referral requested. WD stated the fall was due to R1 not having shoes on. R1 was assessed, no injuries present. Facility records show NP was notified of the incident at 11:25 pm via fax.

On 6/28/25 R1 was found during the medication pass at approximately 5:30 am. Interviews and records state medication aid walked in and observed R1 on the floor and noted a “head injury and resident near [their] bed on the floor.” Facility called 911 and stayed by R1. Records state, “resident unable to give description” of what had happened and that “Resident appeared disoriented.” The incident resulted in unknown head injury, with blood loss. Review of R1 medication records shows they were on a blood thinner.

During record review, LPA noted that physician’s order dated 6/2/25 and 6/16/25 for PRN Tramadol stated, “1 tablet orally at bedtime as needed for pain”. During an interview LPA was told that medication was given the morning after the incident and Medication Administration Record (MAR) showed R1 took a PRN tramadol at 9:55 am on 6/27/25. Interview at 3:20 pm on 7/25/25 with NP, LPA inquired why PRN was ordered for “bedtime”. NP stated prescribed “at night, in case the resident gets tired from the medication, and so they don't fall." Continue on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250717121638
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: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025
VISIT DATE: 08/05/2025
NARRATIVE
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Record reviewed do not show history of falls, pre-assessment documented by F1 states R1 had a mini stroke in March, but “has not fallen…” Interviews with staff for incidents on 6/27/25 state that R1 was at their normal baseline following both incidents. Staff state R1 is usually a little confused and needs prompting. Record review indicates that the care level assessment and Service Plan Report effective date 4/21/25 for R1 shows that R1 requires cueing throughout the day for orientation, escort and cueing for; meals, activities, moving throughout the facility, that R1 requires frequent checks for toileting, brief changes, medications, reminders for daily activities, transfers in and out of bed, bathing, and grooming in the morning and bedtime.

R1 does not have a history of falls prior to entering the facility and has not had falls until the 3 incidents noted above which occurred in a short time frame. Facility followed their protocols, requested emergency services, notified a medical professional, requested PT after a second incident.

Based on record review and staff interviews at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred.

On the allegation: Staff administered a medication that was not prescribed to a resident in care.
It was alleged medication provided to R1 on 6/27/25 did not belong to the R1. The documented order dated 6/2/25 and renewed order on 6/17/25 was provided to the LPA upon request, both were signed by the NP and confirmed during interview with NP on 7/25/25.

Medication was prescribed, but given at 9:55 am which is not following doctor’s order of “1 tablet orally at bedtime as needed for pain.” LPA conducted a Case Management addressing this medication error.

Based on record review and interviews conducted, at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Copy of report provided to facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3