567609831-5-15-2024-29-AS-KHEN-D5RTCX-20240530143729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609831
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:35:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/22/2024 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240422132222

FACILITY NAME:	ROYAL OAKS INN		FACILITY NUMBER:	567609831
ADMINISTRATOR:	JAKOBOVICH, BRANDON		FACILITY TYPE:	740
ADDRESS:	45 ERBES RD		TELEPHONE:	(805) 495-4657
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	80	CENSUS: 40	DATE:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	01:58 PM
MET WITH:	Brandon Jakobovich		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility staff did not assist resident with self administered medications as prescribed
Facility staff did not accurately document resident's medication administration

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 01:58PM and met with Administrator Brandon Jakobovich. Entrance interview conducted.

During today's visit, LPA interviewed Administrator, conducted staff interviews 02:24PM and 02:33PM, and LPA reviewed medications for 3 (three) residents. During the initial complaint visit conducted on 04/23/2024, LPA interviewed Administrator at 01:40PM, toured the facility at 02:18PM, LPA observed Resident #1 (R1), reviewed R1's file and obtained copies of pertinent documents, and at 02:48PM, LPA reviewed medications for 3 (three) residents, including R1. The following was then determined:

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240422132222

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL OAKS INN	FACILITY NUMBER: 567609831
	VISIT DATE: 05/15/2024

NARRATIVE

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The complaint alleges that medications for Resident #1 (R1), who has a diagnosis of dementia, are not being administered as prescribed and not documented accurately on their medication list, as reflected by inaccurate expiration dates listed on the Medication Administration Record (MAR). Interview with both Administrators indicates that R1 has resided at the facility since 2022, previously with their spouse. After their spouse passed away, R1's son became their responsible party. R1's son then did not pay the facility fees and was non-responsive to management's attempts at correspondence. Facility staff indicated they faxed requests to R1's physician for medication refills, however received response faxes indicating R1 was no longer their patient. Administrator contacted the facility's pharmacy provider for R1's medications and Administrator paid the balance on R1's account so that R1's medications would be refilled. In October 2023, Administrators contacted Adult Protective Services (APS) to file a report on R1's son, as the facility was still unable to reach him and R1 continued to accrue a balance at the facility and pharmacy. The facility contracted pharmacy continued to provide medications for R1 through the end of December 2023, after APS had assisted R1 in obtaining medical insurance through a new provider and had brought R1's medications to the facility. Interview revealed that the facility's pharmacy provides the MAR records for the residents at the facility, based on their most recent medication list provided to them. As R1 did not have a physician for some time, and even when R1 got new medical insurance and APS took R1 to the doctor, no new medication list or prescription orders were provided to the facility or the pharmacy. Interview revealed that without getting new orders or a new medication list, the pharmacy will not remove any medications from the MAR, even at the facility's request. Facility staff interviewed indicated that at no time did R1 go without medications. Medications reviewed during both facility visits revealed that the medications were documented and administered as prescribed, on both the centrally stored medication record and the MAR. Based on interview and record review, although the allegations may be valid, at this time there is insufficient evidence to support the allegations, therefore, the allegations that "Facility staff did not assist resident with self administered medications as prescribed" and "Facility staff did not accurately document resident's medication administration" are deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

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