561703345-6-29-2021-29-AS-KBUY-CQCL3M-20230328082409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 06/29/2021
Date Signed: 06/29/2021 06:09:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/14/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210414083514

FACILITY NAME:	TREACY VILLA		FACILITY NUMBER:	561703345
ADMINISTRATOR:	EVANGELINE MICHAYLUK		FACILITY TYPE:	740
ADDRESS:	3482 LOMA VISTA RD		TELEPHONE:	(805) 644-1292
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	0	CENSUS: 24	DATE:	06/29/2021
		UNANNOUNCED	TIME BEGAN:	03:09 PM
MET WITH:	Evangeline Michayluk		TIME COMPLETED:	04:43 PM

ALLEGATION(S):

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Staff used a postural support for a resident without a physician's order
Unqualified staff administered medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced subsequent complaint visit at the facility today.

Concerns were that staff used a postural support for resident #1 (R1) without a physicians order. Interview with staff #2 (S2) on 4/15/21 starting at 12:05 pm revealed that R1 had a seat belt on their wheelchair which was switched out yesterday with one without a seatbelt. Interview with Administrator on 6/29/21 at 3:09 pm revealed that they do not have a physicians order on file for R1's postural support belt. During facility visit at 3:15 pm LPA observed postural support belt on R1's wheelchair which was strapped to the back of the chair. Interview with S2 on 6/29/21 at 3:16 pm revealed that they are using the postural support belt for R1 when they are in the wheelchair. S2 stated that R1 is not able to self release the support belt. S2 provided a copy of R1's physician's order for postural support belt during facility visit and indicated that they requested and received the copy today from the physicians office. LPA observed start date
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210414083514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TREACY VILLA	FACILITY NUMBER: 561703345
	VISIT DATE: 06/29/2021

NARRATIVE

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as 4/14/21 on the physicians order. LPA confirmed with S2 that the facility was using the postural support belt on R1's wheelchair prior to 4/14/21. Concerns were that unqualified staff administered medications. Interview with staff #1 (S1) on 4/15/21 starting at 12:35 pm revealed that they started assisting with medications 3 to 4 years ago. Interview with Administrator on 4/15/21 starting at 1:15 pm revealed that the only documented medication training they have for S1 was 10 hours of medication training on 11/4/2020 to include 4 hours of initial instruction and 6 hours of hands-on shadowing. Administrator also stated that S1 had 4 hours of medication training on 10/6/2020. Administrator stated that S1 was assisting with medications when they started working there. Based on the information obtained during the course of the investigation, the allegations are deemed substantiated at this time.

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20210414083514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TREACY VILLA	FACILITY NUMBER: 561703345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/06/2021 Section Cited CCR 87608(a)(3)	1 2 3 4 5 6 7	87608 Postural Supports. (a)(3) Based on the individual's preadmission appraisal, and subsequent... A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require... if needed to verify the order. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff provided documentation of physicians order for R1's postural support belt for wheelchair during facility visit. Administrator stated that they will submit an exception request for R1's postural belt to CCL by 7/6/21.
	8 9 10 11 12 13 14	Based on LPA's observations and interviews, the licensee did not comply with the section cited above as staff were using a support belt on R1's wheelchair prior to receiving a physician's order which poses a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 07/09/2021 Section Cited CCR 1569.69(a)(1)	1 2 3 4 5 6 7	1569.69 Employees assisting residents with self-administration of medication; training requirements (a)(1) In facilities licensed to… This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self- administration of medications, and 8 hours… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will provide documentation of S1's 24 hours of initial medication training to CCL by 7/9/21.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above as R1 did not complete 24 hours of initial medication training which poses a potential health risk to persons in care.	8 9 10 11 12 13 14

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

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