425850025-6-10-2024-29-AS-KBUY-D6MQEJ-20240627120626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 06/10/2024
Date Signed: 06/10/2024 05:13:47 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
05/24/2024 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20240524153030

FACILITY NAME:	SANTA MARIA TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS: 94	DATE:	06/10/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sanjuana Enriquez		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Staff did not dispense resident’s medication according to doctor’s orders.
Staff did not ensure resident receives contracted amenities.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sanjuana Enriquez, Administrator and Amy Bowman, Designee and explained the purpose of the visit.

On the allegation: Staff did not dispense resident’s medication according to doctor’s orders. It was alleged that for two weeks the facility did not administer Resident 1 (R1) pain medication as prescribed which was stated by Family 1 (F1) to be taken every six hours or as needed (PRN). It was also alleged staff have refused to give R1 pain medication when asked.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

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 4

Control Number 29-AS-20240524153030

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: 06/10/2024

NARRATIVE

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F1 states one day R1 went 13 ½ hours between doses and is now having anxiety and agitation due to the pain.

Interview conducted on 5/24/24 at 3:45 pm, F1 stated R1 was not getting medication as prescribed, R1 had to “chase” medication aids for medication, R1 is calling panicked about not receiving medication, per F1 there was no one there to give lunch medication on 5/24/24.

On 6/3/24 the Designee provided copies of R1’s Medication Administration Records (MARs), May staffing schedule, R1’s Centrally Stored Medication list, which included doctor’s orders, as well as Pallotive care’s updated prescription for Norco and Seroquel. On 6/10/24 LPA requested copies of sign-in sheets, and cross reviewed them with initialed MAR records show there was coverage for all medication pass shifts including 5/24/24.

On 6/10/24 LPA reviewed May medication records for R1. Per MAR records, R1 was receiving all medication prescribed at the correct time. The PRN pain medication, per the MAR record shows from 5/4/24 to 5/23/24 R1 had taken the medication with 7 to 15 hour gaps, records show most time frames were over 11 hours apart. R1’s pattern shows that a 13-hour delay in this medication is consistent with R1’s history. On 5/24/24 this pain management medication was changed to a standing 6-hour distribution per updated doctor’s order. A medication review was conducted by LPA at 12:30 pm with Designee and R1’s medications show that it has been followed as prescribed since 5/24/24.

Based on interviews, and documentation obtained, there is not enough evidence to prove the allegation of, “Staff did not dispense resident’s medication according to doctor’s orders” and it is unsubstantiated at this time.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 29-AS-20240524153030

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: 06/10/2024

NARRATIVE

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On the allegation: Staff did not ensure resident receives contracted amenities. It was alleged that on 5/22/2024, the facility updated either the wi-fi or cable services and since then, per F1, R1 has not been able to watch their personal television (TV) in their room because it is not a smart TV and is not compatible with the new system. F1 states staff told them they will eventually give R1 a compatible TV but not the same size as R1’s current TV. F1 states staff did not advise them of the service change so F1 could make sure that R1 continued to have a working TV available.

Interview with F1 on 5/24/24 at 3:45 pm, they stated R1 was without TV service, F1 stated they had told R1 about the change in services but had not informed F1. F1 said if they would have known ahead of time, they could have provided a new TV. Interview conducted on 6/3/24 with R1 and F1, R1 stated their TV was still not working.

Per interview with Administrator, a notice of TV service interruption was handed out to resident’s inboxes and posted on 5/20/24 that services would be down on 5/22/24 through 5/24/24. When services were restored that is when it was discovered some TVs would not be compatible with the update. Administrator did not know it would affect some resident tv’s until 5/24/24 in which time she called 10 resident’s families to inform them of the issue and that the resident would need a new tv for the upgraded service. Per Administrator, R1 was one of those contacted. On 5/24/24 when a call was made to residents, administrator provided an alternative that residents can use the community TV temporarily. It was also offered that the administrator would go on 5/25/24 to purchase TVs for residents whose families agreed to the purchase and those residents would reimburse the facility for the cost of the TV. Only one resident’s family agreed to have this done. Administrator stated in conversation with F1, F1 said if they were feeling well they would bring one “this weekend”. Administrator also stated a comment was made to F1 that if there was an extra donated TV that would work they would give that to R1, but there was not one after review of their inventory.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240524153030

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: 06/10/2024

NARRATIVE

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TV services is noted in the admission agreement stating “Basic services included” … “the option to connect to cable television.” The agreement does not state the facility will provide a TV, and in interviews conducted with facility, they stated personal TVs are not included in their services.

On 6/1/24 a new remote was purchased for R1’s TV, hoping that would correct the problem with their TV being incompatible, but it did not. On 6/4/24, due to no TV being provided by the family a TV from a respite room was brought in to R1’s room. On 6/10/24 LPA Rankin observed a TV in R1’s room with a news channel broadcasting which picture coming in clearly. Administrator stated she had seen F1 visiting on the weekend but had not appeared to bring in a newer TV.

Based on interviews and the information obtained, there is not enough evidence to prove the allegation of, “Staff did not ensure resident receives contracted amenities” and it is unsubstantiated at this time.

Exit interview conducted, copy of report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC9099 (FAS) - (06/04)

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