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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609782
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:55:34 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
09/18/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250918201939
FACILITY NAME:CARRIES CARE VILLAFACILITY NUMBER:
197609782
ADMINISTRATOR:ACOSTA, MARK RYANFACILITY TYPE:
740
ADDRESS:12550 BURTON STTELEPHONE:
(818) 767-4503
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 3DATE:
09/24/2025
UNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Carrie AcostaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff is mismanaging resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 12:31 PM. LPA met with facility staff who contacted the Administrator Carrie Acosta via telephone call. The Administrator arrived to the facility at 12:35 PM entrance interview was conducted and the reason for the visit was explained.

During today’s visit LPA conducted a brief physical plant tour, reviewed one (1) staff file, conducted a medication audit for one (1) resident and conducted interviews with the Administrator, one (1) staff, and two (2) residents between 12:31 PM and 02:54 PM.

Continued on LIC-9099C

Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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 3
Control Number 29-AS-20250918201939
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: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 09/24/2025
NARRATIVE
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The allegation of “Staff is mismanaging resident's medication.” Alleges that the facility is not giving resident #1’s (R1) medication as prescribed by their physician. LPA reviewed R1’s medications and observed R1’s prescription bottle of Medication #1 (M1). LPA observed M1 to be filled on 08/31/2025 with the administration instructions of “Take one (1) tablet by mouth two (2) times a day as needed for…” LPA observed M1’s dispensed quantity to be sixty (60) pills. LPA observed the M1 bottle to contain three (3) remaining pills. LPA reviewed R1’s Centrally Stored Medication and Destruction Record Sheet (CSMDR) and did not observe M1 to be logged accurately on the CSMDR. This deficiency is addressed in a separate Case Management-Deficiencies report. All of R1’s other medications were logged appropriately on the CSMDR. LPA interviewed the Administrator who stated that R1 consistently asks the facility for more M1 but stated that the facility is following the doctors’ orders on dispensing the medication to R1. LPA was unable to determine the exact start date of the medication due to the incomplete CSMDR but LPA informed the Administrator that there are a minimum of seven (7) M1 pills missing from the bottle. The Administrator confirmed that they are the only staff member trained to handle resident medications. The Administrator denied administering extra medication to R1 despite R1’s requests. The Administrator informed LPA that Staff #1 (S1) witnessed Staff #2 (S2) administering extra an extra M1 pill to R1 on two (2) separate occasions. LPA interviewed S1 with the assistance of telephonic interpretation services and S1 corroborated this statement. S1 informed LPA that S2 had given R1 extra M1 pills on two separate occasions but did not recall the dates this happened. S1 also confirmed that they had given R1 an extra M1 pill on one (1) occasion earlier this morning (09/24/2025). S1’s file was observed, the Administrator was unable to provide LPA with S2’s file. This deficiency is addressed in a separate Case Management-Deficiencies report. LPA observed that S1 did not have the required trainings to handle resident medications. This deficiency is addressed in a separate Case Management-Deficiencies report. LPA informed the Administrator that the three (3) instances of S1 and S2 administering an extra pill still do not explain the discrepancy in the medication count. The Administrator again denied giving R1 extra medication but could not account for the extra missing medication. Two (2) residents interviewed denied missing medications or being given extra medications by facility staff. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff is mismanaging resident's medication.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250918201939
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: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental...
(a) A plan for incidental medical and dental care shall be developed...by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed...
This requirement is not met as evidenced by:
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Administrator agreed to submit a statement of understanding confirming that they will adhere to physician's orders for medication administration. Additionally, Administrator agreed to submit signed statements from each current employee confirming that they will not handle resident medications without...
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Based on observation, interview, and record review the licensee did not comply with the section cited above as R1's M1 medication was not administered as prescribed by their physician on at least 3 separate occasions with at minimum 7 pills missing which poses an immediate health risk to clients in care.
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...Appropriate medication training. Administrator agreed to submit the required documents to CCLD no later than POC due date.
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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: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3