197609562-1-15-2025-29-AS-KHEN-DDEVJQ-20250130152906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609562
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:05:55 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2025 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20250113113045

FACILITY NAME:	APPLEGATE @ SIRIUS		FACILITY NUMBER:	197609562
ADMINISTRATOR:	ALVAREZ, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	2614 SIRIUS STREET		TELEPHONE:	(805) 380-9400
CITY:	THOUSANDS OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	10:52 AM
MET WITH:	Irma Carmona		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff are not properly trained
Staff are mismanaging residents' medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct an initial complaint visit. LPA initially met with facility staff. Licensee arrived shortly after the visit began. Entrance interview conducted.

During today's visit, LPA interviewed staff beginning at 10:54AM, interviewed Licensee, reviewed records and obtained copies of pertinent documents. LPA reviewed medications for 2 (two) residents at 11:48AM, interviewed residents beginning at 01:04PM. The following was then determined:

It was alleged that the Licensee did not provide proper medication training to facility staff. Interviews revealed that staff are trained on medication administration, including education, quizzes, and shadowing training prior to administering medications. LPA reviewed staff files and verified that all staff are trained both initially and annually on medication administration per regulation. The information obtained during the investigation
REPORT CONTINUED ON LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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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Control Number 29-AS-20250113113045

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: APPLEGATE @ SIRIUS	FACILITY NUMBER: 197609562
	VISIT DATE: 01/15/2025

NARRATIVE

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did not include evidence sufficient to corroborate the allegation related to proper staff training. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

The complaint also alleges that the facility is mismanaging residents' medications, including improper preparation and documentation of medications administered. LPA reviewed medications for 2 (two) residents, which were observed to be administered as ordered and documented on both the Centrally Stored Medication and Destruction Record (CSMDR) and the Medication Administration Record (MAR) in accordance with regulation. LPA observed no discrepancies during the medication review. Residents interviewed confirmed their medications are administered by the staff and are given as prescribed. Staff indicated that morning medications are prepared the night before and that during the day they prepare the rest of the day's medications, as time permits. Staff indicated that at no time are medications prepared more than 24 hours in advance. During medication review, LPA observed medications for today's 05:00PM medication pass were pre-prepared. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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