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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850292
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:33:53 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 Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20240110130342
FACILITY NAME:BLUEBIRD HOMEFACILITY NUMBER:
565850292
ADMINISTRATOR:CATABAY, TEDDYFACILITY TYPE:
740
ADDRESS:1484 BLUEBIRD AVETELEPHONE:
(805) 827-3651
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Arlene MartinezTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Questionable death.
Staff gave medication to resident in care without a doctor's order.
Staff insert suppositories to residents in care without proper authorization.
Staff hit residents in care.
Facility does not have adequate staff to meet resident needs.
Residents are not provided proper food service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver findings for the allegations listed above. The LPA met with the Administrator and explained the reason for the visit.

On 01/12/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial visit to investigate the allegations listed above. The LPA arrived at 11:15 a.m. and was greeted by Licensee Arelene Martinez. The LPA explained the reason for the visit. At 11:32 a.m. the LPA requested records pertaining to the investigation. From 12:05 p.m. to 12:55 p.m. the LPA interviewed the Administrator Arlene Martinez.
On 10/ 23/2024, LPA Urena conducted additional interviews, administrator, staff, residents, and residents’ family members. The LPA requested additional records pertinent to the investigation and conducted medication audit at 1:25 p.m.
Continues on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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 5
Control Number 29-AS-20240110130342
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: BLUEBIRD HOME
FACILITY NUMBER: 565850292
VISIT DATE: 10/29/2024
NARRATIVE
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Pg. 2
Questionable deaths
On the allegation of questionable death, the concern of the reporting party (RP) is that sometime in November 2023, two residents’ deaths happen suddenly. To investigate the allegation, LPA Urena interviewed the Administrator and staff and requested documents pertinent to the allegation. Staff (S1) interview revealed that the two residents who had passed away at the facility, did not pass away within a week from each other, and both were receiving hospice services by two different agencies. S1 stated that they were not on duty when R1 and R2 passed away. The staff who was present at the time of R1 and R2 deaths, is no longer working for this facility. The administrator stated that the two residents that passed away at the facility were receiving hospice services, and had indeed passed away at the facility, but not within a week of each other. One resident (R1) passed away in September of 2023, and second resident (R2) passed away in November 2023. The Administrator stated that the staff on duty during the death of R1 and R2 is no longer employed at the facility. LPA Urena reviewed the following documents: Physicians’ reports, medication list, hospice, and death certificates. Record review indicates that R1 was receiving hospice while residing at the facility, and the County of Ventura Death Certificate indicates the immediate cause of death as Cardiopulmonary Arrest, and the leading cause of death as Malignant Neoplasm of breast. R2 was receiving hospice care while residing at the facility, and the County of Ventura Death Certificate indicates the immediate cause of death as Cardiopulmonary Arrest, and the leading cause of death as Alzheimer Disease. On both incidents of death, the facility staff followed procedures by informing R1’s representatives, hospice agency, and the Community Care Licensing Department. Administrator’s and staff interviews also revealed that both R1’s and R2’s health was declining prior to death. Residents’ energy was poor and/or were refusing food intake.

Based on the information received through interviews and record review, the allegation that residents’ deaths were questionable, is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240110130342
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: BLUEBIRD HOME
FACILITY NUMBER: 565850292
VISIT DATE: 10/29/2024
NARRATIVE
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Pg 3.
Staff gave medication to resident in care without a doctor's order.
On the allegation that staff gave resident medication without a doctor’s order, it is the concern of the reporting party that staff was giving Lorazepam (Ativan) to calm the resident, and such medication was not prescribed by the primary physician. To investigate the allegation, LPA Urena interviewed the staff, and the administrator and reviewed medication list (LIC 622). The administrator’s and the staff interviews revealed that R1 was prescribed Lorazepam (Ativan) by the primary physician which was documented in the Centrally Stored Medication and Destruction Record (LIC 622). LPA Urena reviewed the LIC 622 and the list of prescribed medications by the primary physician for R1. Lorazepam (Ativan) 2mg. every two (2) hours or as needed (PRN), was prescribed for anxiety, restlessness, insomnia, and agitation. R2’s primary physician prescribed Lorazepam (Ativan), 2mg. every six (6) hours or as needed. The staff interviews revealed that the nurse would be the person assisting the residents with medication administration. Per the Administrator and staff interviews, when residents pass away, the hospice nurse takes possession of the medications at the facility and takes the medication away to be destroyed.
Based on the information obtained through interviews and record review, the allegation that staff gave medication to resident without doctor’s orders, is deemed Unsubstantiated at this time.

Staff insert suppositories to residents in care without proper authorization.
On the allegation that staff insert suppositories to residents without authorization, it is alleged that staff insert the suppositories to residents when residents are having difficulty with bowel movements. To investigate the allegation the LPA interviewed staff (S1) about the suppositories. The staff stated that they are not allowed to insert suppositories and if the residents are experiencing bowl movement issues, they inform the administrator. The administrator stated that staff informs them of any concerns with residents’ bowel movements or being impacted. The administrator then informs the doctor, or hospice nurse. The administrator stated that staff are trained and are aware that they cannot insert suppositories, as they are not skilled professionals. The LPA interviewed a resident’s (R3) representative about suppositories, as it is indicated in the resident’s hospice list of medications. The R3 representative stated that R3 needed the suppositories when R3 was having bowel movement issues, and they understand that the hospice nurse was the person inserting the suppositories; however, the suppositories are no longer needed since R3 is having regular bowel movements now.
Continues on Page 4.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240110130342
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: BLUEBIRD HOME
FACILITY NUMBER: 565850292
VISIT DATE: 10/29/2024
NARRATIVE
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Based on the information obtained through interviews, the staff and the administrator stated that they understand that facility staff are not skilled professional to insert suppositories to residents. Therefore, the allegation is deemed Unsubstantiated at this time.
Staff hit residents in care.
On the allegation that staff hit resident in care, it is the concern of the RP that staff hit residents in care. To investigate the allegation, LPA Urena interviewed staff and the administrator, residents, and residents’ representatives. The staff denied hitting the residents in care. The administrator stated that they had not received concerns from residents’ representatives or from the residents themselves. The LPA interviewed residents about the care they received from staff, and they stated that they were happy with the care they received and had no concerns. Residents’ representatives and next of kin, stated that they were very happy with the care the staff provided to their residents, and had not received any concern from the residents themselves. During their visit to the facility to visit the residents, the residents’ representatives stated that they had not witness any concerning behavior by staff. Two out of the current

Based on the information obtained through interviews, the residents and the residents’ representatives did not have any concerns about the care being provide by staff and stated that they were not aware of any staff hitting residents in care. Therefore, the allegation that staff hit residents in care, is deemed Unsubstantiated at this time.

Continues on LIC 9099C Page 5.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240110130342
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: BLUEBIRD HOME
FACILITY NUMBER: 565850292
VISIT DATE: 10/29/2024
NARRATIVE
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Pge 5.
Facility does not have adequate staff to meet resident needs.
On the allegation that facility does not have adequate staff to meet the residents’ needs, it is the concern of the RP that facility staff have to work six (6) days a week, and do not get enough rest because the daytime staff also cover the night duties. To investigate the allegation, LPA Urena interviewed staff and the administrator about the work schedule and reviewed the Personnel Roster (LIC 500). The staff stated that they are not made to work but choose to work the schedules needed to assist the facility needs. Staff (S1) stated that they work five (5) days a week during the day shift, and sometimes may assist with the night shift, when needed but not typically. Staff (S2) stated they work four (4) days a week during the day shift. The administrator stated that staff get at least two days off. The LPA has always observed two staff working on the days of the unannounced visits to the facility. Review of the LIC 500 revealed that the facility employees work either two (2), four (4) or five (5) day shifts. Schedules vary for staff, and the staff may work up to 10 hours a day.
Based on the information obtained through the interviews, observation and record review, the facility has adequate staff to meet the needs of the residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.
Residents are not provided proper food service.
On the allegation that residents are not provided proper food service, the concern of the RP is that residents are not being provided with vegetables and fruits. To investigate the allegation, the LPA reviewed the menu, interviewed staff, residents, and conducted an inspection of the food available at the facility. The staff interviews revealed that that the menu usually includes a protein, chicken, rice, beans, pasta and fruit and vegetables and drinks, along with dessert for lunch, breakfast usually includes eggs, bacon, pancakes, oatmeal, toast, etc. The residents get three meals a day and snacks. The residents stated that they like the foods the staff cooks, and when asked to describe the type of foods they receive, the residents stated that they eat eggs, pancakes, toast, oatmeal, pasta, sandwiches, fruit, potatoes, chicken, cookies, and drinks. The residents stated that they receive plenty of food and if they request more, they always get more food. The LPA observed milk, juice, meats, eggs, pasta, vegetables and fruits during the food audit.
Based on the information obtained through observation, and interviews, the LPA observed that residents received a variety of meals and residents are happy with the meals they receive. Therefore, the allegation is deemed Unsubstantiated at this time.
No citations were issued. Exit interview was conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5