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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197608905
Report Date:
03/29/2022
Date Signed:
03/29/2022 02:25:04 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
03/25/2022
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20220325114649
FACILITY NAME:
MY HOME II
FACILITY NUMBER:
197608905
ADMINISTRATOR:
MARK YULE
FACILITY TYPE:
740
ADDRESS:
6753 ESTEPA DRIVE
TELEPHONE:
(661) 219-4906
CITY:
TUJUNGA
STATE:
CA
ZIP CODE:
91042
CAPACITY:
6
CENSUS:
6
DATE:
03/29/2022
UNANNOUNCED
TIME BEGAN:
09:45 AM
MET WITH:
MJ Mclelland
TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is over medicated
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.
LPA conducted a physical plant tour from 9:45-10am to ensure no immediate health and safety issues.
Regarding the allegation above it is alleged that resident #1 (R1) has not been given medication according to physician orders and may have been overmedicated. It is alleged that staff stopped giving a specific medication against physician orders . LPA conducted interviews with facility staff regarding this allegation from 10:30-11:15am. LPA spoke with case manager from Kaiser Palliative Care regarding R1's care from 11:15-11:30am. LPA interviewed residents which included R1 to see how they were doing at the facility from 10-10:30am. LPA reviewed R1's facility file which included medication information and physician orders. LPA reviewed R1's medication compared to R1's medication documentation to see if they matched up from approximately 11:30-12:45pm. Based on interviews and documentation it appears that R1 is being given all their medication according to physician orders. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME
:
Cassandra Harris
LICENSING EVALUATOR NAME
:
Wendell Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
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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