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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850339
Report Date: 01/30/2025
Date Signed: 02/05/2025 09:32:34 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
08/21/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240821151342
FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR:ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 168DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Tina Hernandez, Resident Service CoordinatorTIME COMPLETED:
04:24 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanages resident's medications.
Resident does not receive medication as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Tina Hernandez. The reason for the visit was explained.

On 08/21/2024, Community Care Licensing Division received the above allegations. On 08/29/2024, LPA conducted the initial complaint visit and allegations were discussed with Administrator. Copy of medication records were requested and reviewed. A subsequent complaint visit was conducted on 12/16/2024, LPA conducted interview with the med-tech staff and reviewed the centrally stored medications and records at approximately 1:30pm.

Following is a summary of the allegations and investigation finding:

Allegations “Staff mismanages resident’s medications” and “Resident does not receive medications as prescribed”: (Continue to LIC9099c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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 2
Control Number 29-AS-20240821151342
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: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339
VISIT DATE: 01/30/2025
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
It was reported that resident #1 (R1) had severe fecal impaction and when requested the PRN medication “Bisacodyl” on 08/4/2024 an 08/05/2024, facility staff could not locate the medication. According to reporting party, the “Bisacodyl” was finally located on 08/07/2024. A review of R1’s centrally stored medication records and medication on hand was conducted and found no discrepancies with this PRN medication. There was a supply of this PRN medication from the last refill dated of 4/18/2024 and a new order filled 08/15/2024. During the medications review it was confirmed that staff did have a supply of the “Bisacodyl” on hand in the month of August 2024. R1 reported that it was late in the day when medication was requested on 08/04/2024 and 08/05/2024. R1 could not recall the name of the staff. R1 stated that it was not “Raul the med-tech it was another staff in the med-room”. Staff interviewed denied the allegations. According to staff R1 did not request this specific medication on dates indicated above from the med-techs.

Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff mismanages resident's medications and Resident does not receive medication as prescribed” is deemed Unsubstantiated at this time.

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





SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2