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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601489
Report Date: 12/19/2024
Date Signed: 12/19/2024 06:51:06 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
12/17/2024 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20241217081608
FACILITY NAME:CARRIE'S BOARD AND CAREFACILITY NUMBER:
197601489
ADMINISTRATOR:CARRIE ACOSTAFACILITY TYPE:
740
ADDRESS:8430 COLBATH AVENUETELEPHONE:
(818) 893-7619
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 4DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Carrie AcostaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff could not provide medical paperwork to emergency personnel.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sandra Urena conducted an intimal unannounced visit to investigate the allegation listed above. The LPA arrived at the facility and was greeted by staff. The LPA explained the reason for the visit. The staff called the Licensee Carrie Acosta to inform them of the visit, however the staff could not get in touch with them. Furthermore, the LPA called the licensee, and texted them at their cell phone, but was unable to communicate with them. The LPA requested records pertinent to the allegation at 11:15 a.m. and interviewed the staff at 11:45 a.m. The Licensee arrived at 12:38 p.m.

Staff could not provide medical paperwork to emergency personnel.
On the allegation that staff could not provide medical paperwork to emergency personnel, it is the concern of the Reporting Party (RP) that when emergency personnel responded to a 911 call at the facility and asked facility staff (S1) about R1’s current mental status as well as medical history, S1 stated they did not know. Furthermore, when emergency personnel asked S1 for R1’s medical file or face sheets for personal information, S1 claimed that the residents’ records are not kept on site.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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-20241217081608
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: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
VISIT DATE: 12/19/2024
NARRATIVE
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To investigate the allegation, the LPA reviewed the file for R1, and the file review revealed that the file for R1 was complete and contained medical information, Identification and Emergency Information form (LIC 601), and the Centrally Stored Medication and Destruction Record form (LIC 622). Additionally, the facility had a Register of Facility Residents (LIC 9020) available for review. The LPA interviewed S2 at approximately 11:45 a.m.; S2 stated that on 12/17/2024 they were at the other licensee’s facility, when S1 called them to inform them that EMT personnel were at the facility for a 911 call. R1 had called 911, although R1 was not in distress or had an emergency. S2 stated that they came back to the facility and arrived within 15 minutes of receiving the call from S1. Furthermore, S2 stated that S1 was probably nervous and that is the reason they said that R1’s records were not at the facility, because S1 is never in charge of the residents’ files. S2 added that they were able to show the medical records to the EMT personnel and spoke with the EMT staff’s captain and explained the situation. The LPA was unable to interview S1, as S1 was not available.

Based on the information obtained through credible sources, interviews and record review, the investigation revealed that although the facility may have had a file for R1, S1 did not know how to access the file to provide it to emergency personnel at the time of their request. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D).



Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241217081608
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: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2024
Section Cited
CCR
87506(a)(8-10)
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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff, and emergency personnel…This requirement is not met as evidenced by:
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Licensee to submit proof by 12/31/2024 of residents' Emergency Information readily available for review upon request by EMT and CCL personnel, and training for staff to be informed of the facility's procedures and documentation of residents' files.
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Licensee did not comply with the above citation, as one (1) out of four (4) residents' records were not available at facility upon request for review, which poses a potential health and safety risk to residents.
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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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3