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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 10/12/2022
Date Signed: 10/21/2022 03:31:38 PM

Unsubstantiated


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
09/08/2020 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200908161016
FACILITY NAME:TREACY VILLAFACILITY NUMBER:
561703345
ADMINISTRATOR:EVANGELINE MICHAYLUKFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA RDTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:0CENSUS: 0DATE:
10/12/2022
UNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Patrick TreacyTIME COMPLETED:
11:37 AM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner
Staff are mismanaging resident’s medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a telephone visit with Licensee Patrick Treacy to deliver investigation findings as the facility was closed effective 6/22/21.

Concerns were that staff did not seek medical attention for resident #1 (R1) in a timely manner as R1’s family member asked staff to call 911 on 9/6/20 and 15 minutes later 911 was not called so R1’s family member called 911 themselves. On 9/25/2020 at approximately 11:00 am, Investigations Branch Investigator Laura Garcia conducted an interview with the Reporting Party which revealed that on 9/6/20 R1’s family member asked staff to call 911 and staff waited approximately 15 minutes to dial 911. On 9/9/20 starting at 2:15 pm LPA Rosales conducted an interview with the Administrator, staff on 9/8/22 starting at 12:08 pm and 9/12/22 starting at 4:07 pm, resident family members on 9/13/22 starting at 1:52 pm, staff and resident family members on 9/14/22 starting at 9:49 am, and residents on 9/15/22 starting at 11:35 am. Interview with the Administrator revealed that on 9/6/20 staff called them indicating the R1’s family member was going to call
Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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 2
Control Number 29-AS-20200908161016
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: 10/12/2022
NARRATIVE
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911. Administrator stated that R1 was on Hospice and that they should call Hospice. Administrator stated that R1’s family member insisted they call 911 so they called 911. Interview with staff revealed that R1’s family member called 911 on 9/6/20 for R1 and did not ask staff to call 911. Interview with residents and resident’s family members revealed that they did not have any issues with staff not seeking medical attention in a timely manner.

Investigator Garcia reviewed R1’s medical and hospice records. The records revealed that R1 was admitted to the hospital on 9/7/2020 due to an altered mental state and difficulty speaking. Among several chronic illnesses and hospice care noted there was also pain to the left arm. R1 only reported left upper extremity pain over the proximal end of R1’s humerus which was negative for fractures on x-ray. Both left shoulder and left elbow were x-rayed and showed no evidence of any acute fractures or abnormalities. R1 was discharged home in stable condition. Additionally, a CT scan of the cervical spine was performed, there was no contrast or acute fracture. R1 was placed on Hospice on 6/11/2020.

Based on the information obtained, the allegation that staff did not seek medical attention for resident in a timely manner is unsubstantiated at this time.

Concerns were that staff are mismanaging resident #1 (R1) medications as R1’s medications were being combined and were all being given at 5 pm daily.

On 9/10/20 starting at 2:22 pm, 9/8/22 starting at 12:08 pm and 9/12/22 starting at 4:07 pm LPA Rosales conducted interviews with the staff, resident family members on 9/13/22 starting at 1:52 pm, staff and resident family members on 9/14/22 starting at 9:49 am, and residents on 9/15/22 starting at 11:35 am. Interviews revealed that they are not aware of medications not being given at their appropriate times.

A review of R1’s medication records on 7/22/22 starting at 12:18 pm revealed that R1 was being given their medications at their appropriate times.

Based on the information obtained, the allegation that staff are mismanaging resident’s medications is unsubstantiated at this time.

Exit interview conducted. Today's reports and appeals rights were reviewed and mailed certified mail to the Licensee.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2