565801949-1-17-2025-29-AS-KHEN-DE8QXC-20250225113318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801949
Report Date: 01/17/2025
Date Signed: 01/17/2025 11:32:23 AM

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
01/13/2025 and conducted by Evaluator Angela Barutyan

COMPLAINT CONTROL NUMBER: 29-AS-20250113113028

FACILITY NAME:	APPLEGATE @ DORADO		FACILITY NUMBER:	565801949
ADMINISTRATOR:	EMMA CARMONA		FACILITY TYPE:	740
ADDRESS:	1630 EL DORADO DRIVE		TELEPHONE:	(805) 379-1055
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	6	CENSUS: 5	DATE:	01/17/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Ruben Carmona		TIME COMPLETED:	11:45 AM

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) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint visit at 10:15AM. LPA initially met with facility staff. Licensee Ruben Carmona arrived shortly after the visit began. Entrance interview conducted.

During today's visit, LPA interviewed three (3) staff members beginning at 10:20AM, interviewed Licensee, conducted a medication review for two (2) residents at 10:25AM, reviewed records and obtained copies of pertinent documents, and interviewed residents beginning at 10:55AM. 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 five (5) staff files and verified that all staff handling medications are trained both initially and annually on medication administration per regulation.
Report Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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-20250113113028

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: APPLEGATE @ DORADO	FACILITY NUMBER: 565801949
	VISIT DATE: 01/17/2025

NARRATIVE

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The information obtained during the investigation did not include evidence sufficient to corroborate the allegation related to proper medication training. Records confirmed that all staff handling medications receive proper medication training annually. 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 that Licensee did not provide proper medication training 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 two (2) 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. The MAR form was not pre-filled out or signed and is updated daily as medications are administered. 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 one (1) day in advance. During medication review, LPA observed medications for today's 05:00PM, tomorrow’s 08:00AM, and tomorrow’s 05:00PM medication passes 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: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC9099 (FAS) - (06/04)

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