565801762-3-20-2024-29-AS-KLOZ-D3SS58-20240328133356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801762
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:17:23 PM

Substantiated

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
11/16/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20231116085821

FACILITY NAME:	OMNICARE III		FACILITY NUMBER:	565801762
ADMINISTRATOR:	JOSEPH JOSE		FACILITY TYPE:	740
ADDRESS:	1446 SUFFOLK AVENUE		TELEPHONE:	(805) 496-9592
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	0	CENSUS: 0	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Kinga Kozdron		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Administrator is not on site a sufficient amount of time to manage the daily operations of the facility.

INVESTIGATION FINDINGS:

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On 03/20/2024, Licensing Program Analyst (LPA) Sandra Urena contacted the Facility Licensee to deliver the findings via phone for the allegations listed above. The facility (F#5658017620) had a Change of Ownership (CHOW), with a closing date as of 12/20/2023. LPA Urena read the report to the licensee and the licensee agreed to sign the report.

On 11/18/2023, Licensing Program Analyst (LPA) Sandra Urena arrived unannounced at the facility to conduct the initial 10-day visit to investigate the allegations listed above. The LPA arrived at 10:20 a.m. and was greeted by the staff. Staff contacted the Facility Manager Laila Kulungu, as the Administrator Joseph Jose was not available at the time of the visit. The LPA explained the reason for the visit to Facility Manager (FM) over the phone. At 10:25 a.m., the LPA conducted staff interviews. At 10:45 a.m. the LPA requested documents pertaining to the investigation.
Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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 4

Control Number 29-AS-20231116085821

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: OMNICARE III	FACILITY NUMBER: 565801762
	VISIT DATE: 03/20/2024

NARRATIVE

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The administrator is not on site a sufficient amount of time to manage the daily operations of the facility.

On the allegation that there is no administrator on site to manage daily operations. To investigate the allegation the LPA interviewed staff and responsible parties (RP) for residents currently at the facility. Staff stated that the administrator only comes to the facility when something is needed; the protocol is for the facility manager to contact the administrator if something is needed for the facility. Staff added that "the administrator only stops by the facility once or twice a month when we need something". Responsible parties stated that "they visit the facility almost every day and that they have not seen the administrator in quite a while, maybe about three to four months; the staff seem to be in charge, there are two staff that seem to be the leads of the facility. I have not seen the administrator, I have never met them".

Based on the information gathered through the interviews, the allegation that the administrator is not on site to manage the daily operations, is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted over the phone with the licensee. The report was emailed to the licensee.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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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
11/16/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20231116085821

FACILITY NAME:	OMNICARE III		FACILITY NUMBER:	565801762
ADMINISTRATOR:	JOSEPH JOSE		FACILITY TYPE:	740
ADDRESS:	1446 SUFFOLK AVENUE		TELEPHONE:	(805) 496-9592
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	0	CENSUS: 0	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Kinga Kozdron		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not provide residents with daily activities

INVESTIGATION FINDINGS:

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On 03/20/2024, Licensing Program Analyst (LPA) Sandra Urena contacted the Facility Licensee to deliver the findings via phone for the allegation listed above.
On the allegation that the facility is not providing enough activities for the residents. To investigate the allegation the LPA interviewed staff and responsible parties for residents. Staff stated that they do have some activities for the residents. They take residents for walks as much as the weather permits and if residents want to participate. They provide tv programs, or music that appeals to the residents. They celebrate their birthdays and holidays. Interviews with responsible parties revealed that activities are being offered but some residents do not like to participate, do not like walks, and only likes to watch TV and sports. There used to be a woman that used to come in to play the piano and to do sing along. The residents really like that. I have not seen her in a while. Staff celebrate the residents’ birthdays, play games, and do gift exchanges for the holidays. They used to have walks, now only once in a while, perhaps because of the rainy/cold weather.Based on the information obtained through interviews, it appears that activities are being provided, although not as many or as frequently, however the activities are sufficient according to family members. Therefore, the allegation that the facility is not providing enough activities for the residents, is deemed Unsubstantiated, at this time. Exit interview conducted over the phone. The report was emailed to the licensee.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20231116085821

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: OMNICARE III	FACILITY NUMBER: 565801762
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/20/2024 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 (a) Administrator - Qualifications and Duties-All facilities shall have a qualified…The administrator ...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section…. This requirement was not met by evidence:	1 2 3 4 5 6 7	POC: Facility went through a Change of Ownership on 12/20/2023. No POC required at this time.
	8 9 10 11 12 13 14	Based on information received through staff and residents' RP interviews, the administrator is not sufficient hours on the premises to permit adequate attention to the management of the facility, which poses a potential danger to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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