405802295-2-26-2025-29-AS-KBUY-DEAUUB-20250227145317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802295
Report Date: 02/26/2025
Date Signed: 02/26/2025 12:52:11 PM

Unsubstantiated

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
10/11/2024 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20241011094730

FACILITY NAME:	RESIDENCE IV, THE		FACILITY NUMBER:	405802295
ADMINISTRATOR:	MARCOS, MEYNARD		FACILITY TYPE:	740
ADDRESS:	347 CALLE LUPITA		TELEPHONE:	(805) 549-0328
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 6	DATE:	02/26/2025
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Meynard Marcos Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff administered a felony drug to resident in care.
Staff is not repositioning resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Meynard Marcos and explained the reason for the visit.

On the allegation: Staff administered a felony drug to resident in care. On 10/11/2024, the Department received a complaint alleging resident #1 (R1) tested positive for Fentanyl, a felony drug. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Jauregui.

On 10/14/2024, from 1:25 p.m. to 3:50 p.m., Licensing Program Analyst (LPA) Melisa Rankin conducted the 10-day complaint visit to the facility. LPA Rankin met with Administrator Meynard Marcos and explained the purpose of the visit. LPA requested records pertinent to the investigation. The Administrator was informed the complaint was assigned to the Community Care Licensing Division (CCLD) Investigation Branch (IB) and that the investigator would return at a later date to complete the investigation.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

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-20241011094730

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: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
	VISIT DATE: 02/26/2025

NARRATIVE

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On 10/22/2024, from approximately 11:36am to 3:49pm, Investigator Jauregui conducted interviews with Witness #1 (W1), residents, Administrator, and staff; on 11/06/2024, from approximately 9:05am to 3:46pm, with French Hospital social worker and Central Coast Home Health (CCHH) personnel; on 11/12/2024, at approximately 2:42pm, with R1’s friend; on 11/14/2024, at approximately 1:48pm, with R1’s friend; on 11/19/2024, at approximately 2:55pm, with CCHH personnel; on 11/21/2024, from approximately 2:21pm to 3:44pm, with the Department’s nurse consultant, and attempted interviews with French Hospital social worker and physician; on 12/05/2024, from approximately 2:01pm to 2:52pm, with R1’s friend and attempted to contact French Hospital social worker. In addition, the investigator reviewed French Hospital medical records and facility file documents pertinent to the investigation.

A review of R1’s Physician Report, dated 07/06/2024, lists the primary diagnosis as generalized weakness and the secondary diagnosis as Parkinson’s disease. The report documented R1 had mild cognitive impairment, motor impairment/paralysis with stiff and slow movements, needed minimal assistance with activities of daily living (ADLs), intermittently confused and disoriented, able to follow directions and communicate needs. The report further documented R1 as ambulatory, but not able to independently transfer to and from bed. There was no indication of any drug abuse past or present.

A review of the French Hospital medical records for the period of 9/12/2024 through 10/19/2024 revealed denial of illegal substances, and lab work showed no presence of illegal substances for prior visits on 09/12/2024 and 09/30/2024. The records document on 10/07/2024, R1 was admitted to the French Hospital regarding increased weakness. It was determined R1’s mild cognitive impairment/dementia was progressively worsening. According to the 10/07/2024 record “a urine drug test was conducted on R1 which tested negative for opiates.” “The test also showed Fentanyl < (less than) 1.0 nanograms per milliliter (ng/mL) were found in R1’s system. The records indicate that to be considered a positive result, the concentration value must be greater than or equal to the cut off which is 1.0 ng/mL…” “The exam did not contain the quantitative results. On 10/08/2024, unknown time, under progress notes, the doctor documented a positive exam for the use of Fentanyl.” According to the hospital, R1’s prescribed medications indicated they would not have caused a positive Fentanyl result.

Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20241011094730

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: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
	VISIT DATE: 02/26/2025

NARRATIVE

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Information obtained from the Department’s nurse consultant’s review of R1’s medical records “confirmed a urine test was conducted on R1 on 10/07/2024. The results of this test were negative for the use of Fentanyl. The urine test returned a result of less than 1.0ng/ml which is below the threshold for a positive result. However, the notes of a doctor’s progress notes documented a “positive test”. The nurse consultant could not confirm if a second test was performed and not documented, or if the note was erroneously based on the negative urine exam. The nurse consultant also reviewed a list of medications from the facility and did not find any Fentanyl prescribed for R1.

Information obtained from the interviews conducted found that facility staff denied providing R1 or any other residents with illegal drugs. The residents reported feeling safe at the facility and expressed satisfaction with the staff. R1’s visitors acknowledged occasionally taking R1 out of the facility but denied providing any illegal drugs. One visitor admitted to taking R1 to a pharmacy, where R1 purchased Tylenol, but was unaware of other items purchased on a separate occasion. R1 indicated they received visits from friends but denied any of them provided R1 with any medication or drugs. R1 was aware of the positive test for Fentanyl but indicated they did not know a reason why it was positive. R1 provided various events involving outings with friends while R1 lived at the facility. R1 stated during an outing an event occurred where R1 “wrestled” with individuals who “wanted to fight” and R1 ran away from them but later when investigator summarized R1’s statement, R1 was confused and stated the events never occurred. However, it was noted that R1 is unable to run.

Based on the information obtained from interviews and medical records, the Department’s investigation did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated at this time.

Continued 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 29-AS-20241011094730

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: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
	VISIT DATE: 02/26/2025

NARRATIVE

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On the allegation: Staff is not repositioning resident in care. Hospital records and interviews indicate R1’s medical tests showed R1 had muscle tissue breakdown or Rhabdomyolysis on their right side. Per the allegation, Rhabdomyolysis is common in residents who consistently lay on one side and are not being turned.

A review of R1’s Physician Report, dated 07/06/2024, lists the primary diagnosis as generalized weakness and the secondary diagnosis as Parkinson’s disease. The report documented R1 had mild cognitive impairment, motor impairment/paralysis with stiff and slow movements, needed minimal assistance with activities of daily living (ADLs), intermittently confused and disoriented, able to follow directions and communicate needs. The report further documented R1 as ambulatory, but not able to independently transfer to and from bed. On 2/26/25 LPA interviewed staff regarding R1, both staff stated R1 was able to walk, but was unstable, they also stated R1 would refuse assistance and wanted to be independent. Based on staff interviews, physicians’ documentation, and R1’s ability to leave the facility frequently with visitors, R1 was able to reposition self in bed and could transfer to their wheelchair and walker independently.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC9099 (FAS) - (06/04)

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