191221159-4-17-2023-31-AS-MVAO-CR9U6Z-20230426151909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221159
Report Date: 04/17/2023
Date Signed: 04/17/2023 03:58:56 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230407145736

FACILITY NAME:	MAHARLIKA HOMES		FACILITY NUMBER:	191221159
ADMINISTRATOR:	GARDOSE, NOELLIE L.		FACILITY TYPE:	740
ADDRESS:	17843 CANTARA STREET		TELEPHONE:	(818) 343-3936
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	4	CENSUS: 4	DATE:	04/17/2023
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Monique Gadrose, Aministrator Assistant		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not administer resident's medications as prescribed
Staff do not ensure meals are made available to resident
Licensee does not inform resident’s responsible party of incidents involving resident

INVESTIGATION FINDINGS:

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At 9:55am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with the Administrator Assistant, Monique Gardose, and explained the reason for the visit.

LPA conducted a physical plant walk through, at approximately 10:00am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

Allegation: Staff do not administer resident's medications as prescribed

It was alleged that staff don’t give R1’s medications when R1 needs them. To investigate this allegation, LPA conducted interviews with the Administrator Assistant and two (2) staff members between 10:05am to
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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 31-AS-20230407145736

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAHARLIKA HOMES	FACILITY NUMBER: 191221159
	VISIT DATE: 04/17/2023

NARRATIVE

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10:50am. All staff denied the above allegation and informed LPA that R1’s medications are being delivered in bubble pack and have been always administered as prescribed. LPA made an attempt to interview three (3) out of four (4) residents. Only two (2) out of three (3) residents were able to communicate and addressed no concerns about their medication assistance. LPA reviewed the facility Centrally Stored Medication and Destruction Records (CSMDR) of the random residents receiving medication assistance by the facility staff. Upon review of the medications LPA observed that R1’s prescribed medications were centrally stored by the facility. In addition, LPA observed all R1’s medications were properly registered on the Medication Administration Record (MAR). Based on observation, interviews and record review, there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

Allegation: Staff do not ensure meals are made available to resident

Regarding the allegation that staff do not ensure meals are made available to residents, LPA's interview with three (3) out of four (4) residents revealed that the facility provides three (3) meals and snacks in between every day and that they all have an access to the kitchen at any time. Two (2) out of three (3) residents also informed LPA that the staff will provide an extra meal upon request. In addition, interview with the Administrator Assistant and two (2) staff members revealed that R1 eats very frequently and never had any concerns and that the staff will also customize food being served upon resident's request. Based on the information gathered during this visit, this allegation is deemed Unsubstantiated at this time.

Allegation: Licensee does not inform resident’s responsible party of incidents involving resident

It was alleged that R1 was hit by the roommate and the incident was not reported to R1's responsible party. To investigated this allegation, LPA interviewed Administrator Assistant, two (2) staff members and three (3) residents. All staff members and (2) residents denied ever witnessing R1 being hit by another resident and informed LPA that no such incident had occurred with R1. In addition, two (2) out of three (3) residents informed LPA that due to R1's medical condition they prefer to stay away from R1 and have a minimum interaction/communication. Based on the information gathered during this visit, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC9099 (FAS) - (06/04)

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