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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800984
Report Date: 11/20/2024
Date Signed: 11/20/2024 01:08:17 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
08/19/2024 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20240819125304
FACILITY NAME:PHYLLIS FAMILY HOMEFACILITY NUMBER:
565800984
ADMINISTRATOR:LORRAINE MEDINAFACILITY TYPE:
735
ADDRESS:2445 EAST PHYLLIS STREETTELEPHONE:
(805) 581-0751
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:4CENSUS: 4DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Lorraine MedinaTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff do not distribute resident's medications as prescribed
Staff do not ensure that medications are stored locked and inaccessible to residents in care
Staff are transferring medications from its original container
Licensee does not ensure that a staff has required training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 09:17 AM. LPA met with facility staff who contacted the facility Administrator Lorraine Medina. The Administrator arrived to the facility at 10:25 AM. Entrance interview conducted and the reason for the visit was explained.

During the initial visit on 08/28/2024, LPAs Trevor Byrne and Kelly Dulek conducted a physical plant tour, conducted interviews with the Administrator, two (2) staff members, and two (2) residents between 09:52 a.m. and 01:00 p.m., conducted staff and resident file review at 10:14 a.m., and obtained copies of pertinent documents relevant to the investigation.

During today’s visit LPA conducted a brief physical plant tour, interviewed two (2) staff, one (1) resident, the facility Administrator and conducted file review between 09:17 AM and 11:20 AM.
Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion: 7
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 3
Control Number 29-AS-20240819125304
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: PHYLLIS FAMILY HOME
FACILITY NUMBER: 565800984
VISIT DATE: 11/20/2024
NARRATIVE
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The allegation of “Staff do not distribute resident's medications as prescribed” alleges that facility staff do not distribute resident’s medications and place medications in an unlocked drawer for Resident #1 (R1) to retrieve themselves and do not supervise R1 when they take their medications. LPA Byrne observed the facility’s medication cabinet to be locked and R1’s medications to be centrally stored. LPA interviewed R1. R1 stated that facility staff will place their medication for the morning into a container and hand it to R1 to take. R1 confirmed that staff watch them take the medications and additionally confirmed that facility staff have not missed medication administration previously. LPA spoke with facility staff #1 (S1), S1 confirmed that they handle medication for the residents in the facility. S1 stated that it is procedure to keep the medications locked and inaccessible to clients in care. S1 confirmed that they secure the medications after distributing them to clients. LPA reviewed medications for two (2) residents. Both resident’s medications were documented appropriately on their centrally stored medication and destruction record sheets as well as on their respective medication administration record sheets. LPA confirmed that the medication count for two (2) residents matched what was documented on both sheets. Based on the information obtained during the physical plant tour, record review, and interviews there is not sufficient evidence to support the allegation of staff do not distribute resident's medications as prescribed. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Staff do not ensure that medications are stored locked and inaccessible to residents in care” alleges that facility staff do not ensure that resident medications are stored locked and inaccessible to residents in care. On both the 08/28/2024 visit and today’s visit (11/20/2024) LPA Byrne observed the facility’s medication cabinet to be locked and inaccessible to clients in care. LPA spoke with S1, S1 confirmed that they handle medication for the residents in the facility. S1 stated that it is procedure to keep the medications locked and inaccessible to clients in care. S1 confirmed that they secure the medications after distributing them to clients. LPA Byrne interviewed R1. R1 stated that they have not accessed the medication cabinet without staff present to distribute their medications. R1 confirmed that staff have never asked them to grab their medications from the closet alone. Based on the information obtained during the physical plant tour and interviews there is not sufficient evidence to support the allegation of staff do not ensure that medications are stored locked and inaccessible to residents in care. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.
Continued on LIC 9099C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240819125304
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: PHYLLIS FAMILY HOME
FACILITY NUMBER: 565800984
VISIT DATE: 11/20/2024
NARRATIVE
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The allegation of “Staff are transferring medications from its original container” alleges that facility staff transfer resident medications from their original prescription bottles. LPA Byrne observed the medication cabinet to contain morning/night 1-day pill organizers for the client’s medications. LPA Byrne observed the containers to be empty. LPA interviewed S1 who stated that they will place the medications for the morning into the container before handing them to clients to self-administer. S1 confirmed that the facility does not prep medications more than one (1) day in advance. Based on the information obtained during observation and interviews there is not sufficient evidence to support the allegation of staff are transferring medications from its original container. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Licensee does not ensure that a staff has required training” alleges that the facility does not ensure employees have the required trainings prior to working with clients. LPA Byrne reviewed the employee files for two (2) facility staff members. Both staff were hired this year and have been working for the facility for about six (6) months. Both employee files contained records of the onboarding training conducted by the facility’s Administrator. LPA confirmed that the trainings provided met the requirements of Title 22 regulations. Additionally, both employee files were observed to contain valid 1st aid/CPR cards. LPA visited the Red Cross website and confirmed that the cards are valid and are within their expiration dates. LPA interviewed the facility Administrator. The Administrator stated that they provided the new employees with required trainings at the time they started working for the facility. The Administrator confirmed the contents of the trainings. LPA interviewed two (2) staff members. Both staff confirmed that they received training at the time they were hired, and both confirmed that the trainings were provided by the facility Administrator. Based on the information obtained during interviews there is not sufficient evidence to support the allegation of Licensee does not ensure that a staff has required training. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

No deficiencies were cited during today’s investigation. A copy of the report was printed and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3