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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609849
Report Date: 08/18/2023
Date Signed: 08/20/2023 08:49:30 AM

Document Has Been Signed on 08/20/2023 08:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PCS - FERNWOODFACILITY NUMBER:
567609849
ADMINISTRATOR:DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 4CENSUS: 4DATE:
08/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Dadesii "DiDi" DanielTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit to the facility. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA and QAS initially met with lead staff 1 (S1) as the administrator was out of town. Administrator DiDi Daniel arrived at the facility at 1:30 p.m. LPA explained the reason for the visit.

During the course of investigating two complaints (29-AS-20230412125937 and 29-AS-20230816091820) other deficiencies were observed.

At 11:50 a.m. LPA and QAS reviewed medications and records. It was found that Client 1 (C1) missed/refused their two 4:00 p.m. medications. However, the administrator failed to report this missed medication to TCRC or Community Care Licensing (CCL).

In addition, there was a note written by staff to discontinue one of C1's medications but there was no physician's order found to discontinue the medication. There was another staff note stating the same medication was having the dosage changed, however there was no physician's order stating such. C1 has not been taking this medication as prescribed for more than a month. During LPA's visit the administrator reached out to C1's physician and found the dosage had been changed but the prescription had not been called in to the pharmacy, nor did the physician send a copy of the order to the facility. The administrator will follow up to ensure the order and medication are received and C1 gets back on the medication immediately.

Lastly, LPA found that the Centrally Stored Medication and Destruction Record (CSMDR) for all clients were incomplete.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview was conducted. Report and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2023 08:49 AM - It Cannot Be Edited


Created By: Teresa Camara On 08/18/2023 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PCS - FERNWOOD
FACILITY NUMBER: 567609849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
80075(k)(7)

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80075 Health Related Services. (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year...
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Administrator will arrange for all staff to attend medication training, including how to complete the CSMDR and submit evidence of training to CCL by 8/25/23.
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This requirement was not met as evidenced by:Based on LPA's review of medications records, all of the Centrally Stored Medication Records were incomplete, which posed a potential health and safety risk to residents in care.
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Type B
08/25/2023
Section Cited
CCR80061(b)(1)(

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80061 Reporting Requirements. (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any
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Administrator will conduct reporting requirements training with all staff and submit evidence of training to CCL by 8/25/23.
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unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by: Based on LPA's medication review, LPA found a missed medication that was not reported, which posed a potential health and safety risk to residents in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2023 08:49 AM - It Cannot Be Edited


Created By: Teresa Camara On 08/18/2023 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PCS - FERNWOOD
FACILITY NUMBER: 567609849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
80075(b)(5)(B)

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Health Related Services. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:

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Administrator will arrange for all staff to attend medication training and submit evidence of training to CCL by 8/25/23.
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Based on record review and interview, the licensee failed to ensure the change in C1's prescription was received and called into the pharmacy, which posed an immediate health and safety risk to clients in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023


LIC809 (FAS) - (06/04)
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