565850233-10-11-2023-29-AS-DPEA-CX5P97-20231031110641

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850233
Report Date: 10/11/2023
Date Signed: 10/11/2023 01:59:34 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
10/03/2023 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20231003133023

FACILITY NAME:	LIGHTFULLY-MOONBEAM		FACILITY NUMBER:	565850233
ADMINISTRATOR:	YVETTE LLANOS		FACILITY TYPE:	772
ADDRESS:	1247 LA PERESA DRIVE		TELEPHONE:	(858) 692-5374
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	6	CENSUS: 4	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Yvette Llanos		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not provide adequate food service
Staff did not meet residents' needs
Staff did not provide a safe and comfortable environment for residents
Staff mismanaged residents' medication
Untrained staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA met with administrator/program director Yvette Llanos and explained the reason for the visit.

At 9:30 a.m. LPA met with staff 1 (S1) and discussed allegations. S1 called the administrator to see when she would be arriving. The administrator arrived at 9:50 a.m. LPA interviewed the administrator and reviewed records between 9:53 a.m. and 11:35 a.m. LPA conducted a brief facility tour at 11:35 a.m. LPA conducted an interview with staff 2 (S2) at 11:50 a.m. LPA conducted an interview with S1 at 12:07 p.m.

(continued on page 2; 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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-20231003133023

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: LIGHTFULLY-MOONBEAM	FACILITY NUMBER: 565850233
	VISIT DATE: 10/11/2023

NARRATIVE

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(continued from page 1; 9099)

Regarding the allegation staff did not provide adequate food service:
Specifically, the allegation was that client 1 (C1) was not served dinner on C1's date of admission. The administrator explained that the admission process to the facility can be long. C1 was in an assessment meeting when dinner was served. When their assessment was complete they were offered food for dinner. S2 recalled C1 had potatoes, macaroni and cheese, and leftover chicken. There were ribs that were served for dinner but there were none left by the time C1 was eating dinner. There were other options available and C1 did eat dinner. The administrator recalled asking C1 if they were still hungry and C1 stated they were not still hungry. Based on information from staff, C1 did have a meal for dinner on C1's date of admission. Therefore, the allegation is deemed unsubstantiated at this time.

Regarding the allegation staff did not meet residents' needs:
This allegation was regarding C1 not receiving the expected therapy during their stay as well as not receiving medication for acute short-term medical symptoms. In addition, it was alleged things like scheduled activities were not conducted due to lack of staffing. LPA interviewed the administrator, S1 and S2. C1 was not at the facility for very long. On C1's admission date there was a lot to go over and assessments to complete in order to understand C1's needs. The second day C1 had to receive a physical in order for the required physician's report to be completed so C1 did not get a full day of program. The third day was a full day of program. The fourth day C1 had packed their things and informed the administrator they were leaving. C1 went to an offsite group session that day with the other clients while the administrator contacted the psychiatrist to get approval to release all of C1's medications to them. In addition, the administrator provided a copy of the staff schedule and a copy of the program schedule as it was alleged on one of the days (C1's last day at the facility) the clients were supposed to be on an outing. The schedule shows the outing was to occur at 3:00 p.m. and prior to that there were two offsite group sessions planned for all clients. There was one staff and the administrator at the facility that day. The staff transported the clients to the offsite group sessions. There was no indication this facility was understaffed that day; they had a total of four clients. Lastly, the administrator stated that on the day C1 went to get their physical staff stopped at a store to take C1 inside to pick up some over the counter medication C1 chose. Staff returned to the facility with the medication and contacted the psychiatrist to get an order for the over the counter medication C1 wanted to take. The facility staff did not ignore C1's symptoms. Based on record review and interviews, this allegation is deemed unsubstantiated at this time.
(continued on page 3; 9099-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20231003133023

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: LIGHTFULLY-MOONBEAM	FACILITY NUMBER: 565850233
	VISIT DATE: 10/11/2023

NARRATIVE

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(continued from page 2; 9099-C)

Regarding the allegation staff did not provide a safe and comfortable environment for residents:
This allegation was regarding the stairs not being safe and there was only one area for residents to relax when not in a session as they are not allowed to hang out in their bedrooms. The administrator confirmed they tell clients to stay out of their bedrooms during program hours of 9:00 a.m. to 5:00 p.m. unless they are suffering from a medical issue such as a migraine or severe cramps. If clients are not in a session they can relax in multiple areas of the facility. Some clients choose to lay down on the sectional sofa in the living room. LPA observed client 2 (C2) laying down and relaxing on the short side of the sectional. There were chairs and the other side of the sectional available for other clients. In addition, there is an arts and crafts room, dining room, group sessions room with lots of seating and a smaller sitting area downstairs; all of these rooms are available to clients. The stairs were observed to be in good condition. The facility also has reflective tape on the edge of the stairs to prevent trips. This facility has a fire clearance for ambulatory clients only. LPA did not observe anything concerning regarding the stairs and LPA observed multiple areas of the facility available for clients' use. Based on these observations, this allegation is deemed unsubstantiated at this time.

Regarding the allegation staff mismanaged residents' medication:
This allegation was regarding the concern about staff not indicating what medications they were giving to clients and staff were ignoring signs of client 3 (C3) and client 4 (C4) being overmedicated. LPA reviewed the medication administration records and medication orders for C1, C3 and C4. All medications appeared to be given as prescribed. LPA interviewed the administrator, S1 and S2 regarding medication administration. The facility has a nurse (LVN) who usually does the medication pass during the day. All staff are trained in medication administration. The administrator, S1 and S2 were interviewed about how they conduct the medication pass. They stated they have the client come to the medication room, ask the client for their name and date of birth, confirm that information on the electronic medication record as well as the physical drawer where that client's medications are stored. Then they go to each medication individually, check the time of day the medication is taken, medication route (oral, injection, etc.), name of medication and dosage, read

(continued on page 4; 9099-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20231003133023

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: LIGHTFULLY-MOONBEAM	FACILITY NUMBER: 565850233
	VISIT DATE: 10/11/2023

NARRATIVE

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(continued from page 3; 9099-C)

that information to the client, hand the bottle to the client and observe them take the medication out of the bottle and take the medication. Then they move on to the next medication that client takes. After medications are taken they have the client sign indicating they took each medication and the name of the staff observing the client is also noted. LPA inquired if any staff recalled seeing C3 or C4 exhibit signs of being overmedicated. Staff denied observing that but stated if there are ever any issues like that it would be discussed with the client's psychiatrist (or other prescribing physician). The administrator stated that C3 complains of being tired and C3 has been discussing that with their psychiatrist. Based on the interviews and records review, medications appear to be given as prescribed and any side effects have been discussed with the prescribing physician, therefore this allegation is deemed unsubstantiated at this time.

Regarding the allegation of untrained staff:
This allegation stated staff leading group sessions were not properly trained and staff passing medications were not trained. LPA interviewed the administrator, S1 and S2 as well as reviewed training records. LPA also obtained a copy of the facility program schedule for the week of 9/25/23 - 10/01/23. Staff leading individual sessions and most group sessions are certified Associate Marriage and Family Therapists (AMFT). The administrator leads some of these groups too and she is a Licensed Marriage and Family Therapist (LMFT). There are a few groups led by Client Care Technicians (CCT); those groups are things such as breathing exercises and watching/discussing TED Talks about psychiatric issues. The administrator is required to complete continuing education to maintain her license. Other staff have required training as well. Some of the training is in person and some of the training is done online through Relias. Medication administration training is conducted by the facility's nurse and online through Relias. Based on interviews and records review, this allegation is deemed unsubstantiated at this time.

No deficiencies were observed. Exit interview conducted and a copy of the report provided to the administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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