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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609023
Report Date: 10/04/2022
Date Signed: 10/04/2022 11:38:05 AM

Document Has Been Signed on 10/04/2022 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRIMROSEFACILITY NUMBER:
197609023
ADMINISTRATOR:UNKNOWNFACILITY TYPE:
740
ADDRESS:8107 DE SOTO AVETELEPHONE:
(323) 387-2755
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 5DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mubeen NaimuddinTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit due to an incident that was reported to licensing. On 10/2/22 staff #1 (S1) gave resident #1 (R1) the wrong medication. S1 realized their error and notified the licensee and emergency services was then called along with poison control. R1 was observed and it was found that R1 did not need to be transported to the hospital due to the medication they were given was a vitamin. This same incident happened with R1 and S1 on 9/27/22 and R1 needed to be hospitalized. R1 was discharged back to the facility on 9/30/22 after being hospitalized. S1 was then given medication training along with the rest of the staff. Since this incident on 10/2/22 S1 has been terminated from their position, due to this being the second incident within the past two weeks. Immediate civil penalty of 250 dollars issued for violation of the same section within a calendar year. Deficiency cited on LIC 809 D. Appeal Rights explained. Exit interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2022 11:38 AM - It Cannot Be Edited


Created By: Wendell Smith On 10/04/2022 at 08:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE
FACILITY NUMBER: 197609023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
Section Cited
CCR
87411(a)

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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by:
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S1 was terminated from their position. Civil penalty of 250 dollars issued for violation of same section within a calendar year.
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Based on interviews conducted R1 was given the wrong medication by facility staff which posed an immediate health and safety issue for R1. This was the second instance of this happening with R1 being given the wrong medication by S1.
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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.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Wendell Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
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