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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850240
Report Date: 06/13/2025
Date Signed: 06/13/2025 04:36:53 PM

Substantiated


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
06/10/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20250610122305
FACILITY NAME:VARIEL OF WOODLAND HILLS, THEFACILITY NUMBER:
195850240
ADMINISTRATOR:LOURDES BUSTAMANTEFACILITY TYPE:
740
ADDRESS:6233 VARIEL AVETELEPHONE:
(818) 651-6018
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:436CENSUS: 363DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica SaksTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff did not properly assist resident with self-administration of medications as prescribed.
Reporting requirements are not being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:00 a.m., the LPA met with staff and explained the reason for the visit. At 9:10 a.m., the Executive Director (ED), Allison Marty met with the LPA.

At 9:14 a.m., the LPA conducted an interview with the ED. At 9:49 a.m., the LPA requested and obtained copies of pertinent documents. Starting at 10:00 a.m., the LPA reviewed Resident #1 (R1’s) records. At 11:26 a.m., the LPA, along with the Wellness Director conducted a brief physical plant tour. Between 12:22 p.m. and 1:38 p.m., the LPA conducted a review of medication and medication documentation with the Wellness Director for eleven (11) residents. Between 9:37 a.m. and 1:43 p.m., the LPA conducted interviews with three (3) staff and three (3) residents.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
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 3
Control Number 29-AS-20250610122305
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: VARIEL OF WOODLAND HILLS, THE
FACILITY NUMBER: 195850240
VISIT DATE: 06/13/2025
NARRATIVE
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Regarding the allegation: 1.) Facility staff did not properly assist resident with self-administration of medications as prescribed. On 06/10/2025, the Department received a complaint alleging staff not properly assisting Resident #1’s (R1’s) with the self-administration of R1’s liquid Escitalopram medication as prescribed. During today’s visit, the LPA reviewed R1’s records including but not limited to progress notes, Medication Administration Record (MAR), and resident appraisal. Per R1’s prescription order, on 04/22/2025, R1 was prescribed Escitalopram 5mg/ 5mL oral solution (Lexapro) to be taken 10 mL (10 mg) by mouth daily. Interview with the Wellness Director, Jessica Saks revealed that on 05/10/2025, she conducted an audit on R1’s medication. Upon the audit, it was revealed that Staff #1 (S1) did not properly assist R1 as S1 prepared and gave R1 5mL of Escitalopram oral solution instead of the 10 mL as prescribed. Jessica S. explained that S1 admitted to the medication error and has since been removed as a medication technician. Jessica S. stated that an exact date of the medication error was not given but believes that the error occurred between 04/24/2025 and 04/26/2025. Jessica S. stated that they self-reported the medication error to Community Care Licensing on 05/15/2025. Jessica S. explained that an in-service medication training was held on 05/10/2025 with staff regarding medication procedures and protocols. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff did not properly assist resident with self-administration of medications as prescribed” is deemed Substantiated at this time. Regarding the allegation: 2.) Reporting requirements are not being met. It was alleged that the facility staff failed to report all of Resident #1’s (R1’s) medication refusals to R1’s responsible person. Interview with the Wellness Director, Jessica Saks revealed that facility staff do and are supposed to communicate with families or responsible persons and doctors when a resident refuses medications or care. Per record review, and interview R1 refused Escitalopram 5mg/ 5mL oral solution on 05/07/2025 and facility staff did not report the refusal to R1’s responsible person. The LPA reminded the ED and Jessica S. that facility staff should be reporting any incident which threatens the welfare, safety or health of a resident such as refusal of medication. The LPA also reminded Jessica S. and the ED that facility staff should be documenting their efforts and form of communication with families, responsible persons and doctors. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Reporting requirements are not being met” is deemed Substantiated at this time.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).
Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250610122305
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: VARIEL OF WOODLAND HILLS, THE
FACILITY NUMBER: 195850240
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2025
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Within 24 hours, the ED will provide the LPA with proof of medication training.
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Based on record review & interviews, the licensee did not comply with the section cited above, staff did not properly assist R1’s medications per physician’s order which poses an immediate health and safety risk to residents in care.
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Type B
06/20/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements(a) ... (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident…This requirement is not met as evidenced by:
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Wellness Director stated they will submit a statement of understanding confirming that they understand the importance of reporting any incidents, including medication refusal to residents’ responsible persons.
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Based on interviews & records review, the licensee did not comply with the section cited above as the Licensee did not report to R1’s responsible person of R1’s medication refusal which poses a potential health, safety, or personal rights risk to residents in care.
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Additionally, Wellness Director stated that an in-service training regarding reporting requirements will be conducted and proof will be sent to the LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3