<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 08/14/2023
Date Signed: 08/14/2023 10:47:43 AM

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
08/01/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230801143754
FACILITY NAME:VARENITA OF SIMI VALLEYFACILITY NUMBER:
567610007
ADMINISTRATOR:VEIS, MARGIEFACILITY TYPE:
740
ADDRESS:3921 COCHRAN STREETTELEPHONE:
(805) 327-1100
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:110CENSUS: 87DATE:
08/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margie VeisTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that residents are receiving their medications as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 08/04/2023 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Executive Director (ED), Margie Veis and the reason for the visit was explained. Entrance interview.

During the initial visit on 08/04/2023, the LPA conducted a tour of the facility to ensure there are no health and safety hazards at 10:48 a.m., conducted an interview with the Health Services Director and one resident at 10:15 a.m. and 10:59 a.m., and obtained copies of pertinent documents relevant to the investigation at 11:30 a.m.

(Report Continued on LIC 9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
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 5
Control Number 29-AS-20230801143754
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: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
VISIT DATE: 08/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Report Continued from LIC 9099...)

It was alleged that staff do not ensure that residents are receiving their medications as prescribed. It was reported that residents were given different medication from what is prescribed. Review of records revealed that Resident #1 (R1) has two (2) PRNs for pain medication which include Acetaminophen 500mg oral tablet and Acetaminophen-Codeine 300mg-30mg oral tablet. The staff utilize the medication administration record (MAR) to also keep track of the PRN medications being administered to residents. Interview conducted with resident revealed they are not sure what medication is given to them; however, the medication that is given to manage the pain helps them to go to sleep at night. Furthermore, although R1 may not know what medication they are taking, the staff is aware of which medication to administer to R1 by following the prescribing doctor’s order on file. Based on record review and interviews conducted, the Department does not have sufficient evidence to support the allegation of “staff do not ensure that residents are receiving their medications as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/01/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230801143754

FACILITY NAME:VARENITA OF SIMI VALLEYFACILITY NUMBER:
567610007
ADMINISTRATOR:VEIS, MARGIEFACILITY TYPE:
740
ADDRESS:3921 COCHRAN STREETTELEPHONE:
(805) 327-1100
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:110CENSUS: DATE:
08/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margie VeisTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly managing residents' medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 08/04/2023 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Executive Director (ED), Margie Veis and the reason for the visit was explained. Entrance interview.

During the initial visit on 08/04/2023, the LPA conducted a tour of the facility to ensure there are no health and safety hazards at 10:48 a.m., conducted an interview with the Health Services Director and one resident at 10:15 a.m. and 10:59 a.m., and obtained copies of pertinent documents relevant to the investigation at 11:30 a.m.

(Report Continued on LIC 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230801143754
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: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
VISIT DATE: 08/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Report Continued from LIC 9099A...)

It was alleged that staff are not properly managing residents' medications. It was reported that several residents’ prescribed narcotics had gone missing. Information obtained during the course of the investigation revealed the facility conducted an audit on residents’ narcotic inventory after several residents’ medication had gone missing. The audit revealed there were at least two (2) residents that had both Tylenol with codeine and Oxycodone missing from inventory. Interviews conducted with staff revealed the narcotics were searched throughout the medication room drawers, cabinets, and resident’s prescription medication, but were still not found. Staff stated R1’s doctor was notified to have new order sent to replenish missing narcotics. Additionally, Resident #2’s (R2’s) doctor was also notified; however, staff requested that R2’s prescription for narcotics be discontinued as R2 has not been at the facility for about one (1) month. Furthermore, R1 and R2’s missing controlled medication has not been found as of today. Based on all the information gathered during the course of the investigation, the above allegation, “staff are not properly managing residents' medications” is deemed Substantiated at this time.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D). Failure to correct citations can result in civil penalties.



Exit interview conducted. Citation issued. A copy of the Appeal Rights and Report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230801143754
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: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2023
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee will conduct a training with staff regarding Regulation 87465 and submit proof to CCL.

POC has been met.
8
9
10
11
12
13
14
Based on record review and interviews, the licensee did not comply with the section cited above as narcotics, a controlled medication which is being centrally stored went missing without a trace, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5