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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801978
Report Date: 01/18/2024
Date Signed: 01/18/2024 02:13:51 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
01/10/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240110170313
FACILITY NAME:FAMILYCARE COTTAGE IVFACILITY NUMBER:
565801978
ADMINISTRATOR:DEBRA BRYANTFACILITY TYPE:
740
ADDRESS:825 CALLE CEDROTELEPHONE:
(805) 380-4108
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Debra BryantTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Medication is not being administered as prescribed.
INVESTIGATION FINDINGS:
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At 9:35 a.m. Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with staff Josefina Jimenez Galindo and was explained the reason for the visit. Licensee Debra Bryant arrived shortly. Entrance interview conducted.

During today's inspection, between 9:40 a.m. and 1:30 p.m., the LPA interviewed the Licensee, two staff, conducted a medication audit, and obtained copies of resident records and other pertinent documents relevant to the investigation.

Report will continue on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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 2
Control Number 29-AS-20240110170313
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: FAMILYCARE COTTAGE IV
FACILITY NUMBER: 565801978
VISIT DATE: 01/18/2024
NARRATIVE
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On the allegation that the “Medication is not being administered as prescribed”, it is the RP’s concern that a staff member (S1) has been stealing Norco medication from residents. To investigate the allegation, LPA Cortez interviewed the Licensee, staff and conducted a medication audit for all six (6) residents. Licensee and staff interviews revealed that there was a recent incident of missing Norco medications possibly involving S1, however it occurred in a different facility owned by the Licensee and has been reported to Community Care Licensing. Staff interviews also revealed that they have not seen any staff steal medications from residents, do not have any concerns of residents not being administered their prescribed medications, and that S1 no longer works at this facility. At 11:00 a,m, the LPA conducted a medication audit and reviewed the Centrally Stored Medication and Destruction Record (CSMDR), the Medication Administrative Records (MAR) along with the medications in their bubble packs/bottles for the month of January of this year. LPA's record review of all six (6) residents' MAR, CSMDR, and medications revealed each resident was administered their medications as prescribed from 1/1/2024 to present, at this time. Based on interviews conducted, and medication audit, the department does not have sufficient evidence to determine that Medication is not being administered as prescribed. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
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