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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802444
Report Date: 11/18/2024
Date Signed: 11/18/2024 04:24:15 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
07/31/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240731145531
FACILITY NAME:LAND OF ENCHANTMENT 1 BOARD AND CARE LLCFACILITY NUMBER:
565802444
ADMINISTRATOR:ROXANA LARAFACILITY TYPE:
740
ADDRESS:78 W GAINSBOROUGH RDTELEPHONE:
(805) 601-5202
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
11/18/2024
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not properly manage resident's medication.
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver finding regaring above noted allegations. LPA initially met with staff who called the administrator. LPA spoke with administrator and explained the reason for the visit.

On 07/31/2024, Community Care Licensing Division (CCLD) received the above listed allegations. Inital complaint visit was conducted on 08/07/2024. Interview was conducted with staff and residents. Also resident records were reviewed.

Following is a summuary of the allegations and investigation finding.
Regarding allegation "Staff did not properly manage resident's medication": Information was reported that facility staff documented the wrong dose of resident #1's Metformin medication. During the intial complaint visit and today's visit former resident's (R1) records including but not limited to R1's medication records were reviewed and discussion was held with Administrator. (Continue to LIC9099c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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 2
Control Number 29-AS-20240731145531
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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444
VISIT DATE: 11/18/2024
NARRATIVE
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According to Administrator the medication release list dated 7/28/2024 did have a typo (metformin 50mg) however the centrally stored medication record used by facility which documents all medications that R1 was provided as prescribed is correct and accurate. LPA reviewed the centrally stored record for R1 and observed no descripencies. According to administrator and staff R1 was receiving the correct dose of metformin (500mg) and the medication was correctly documented on the centrally stored records from (move-in to move-out) 5/2020-7/2024. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation "Staff did not properly manage resident's medication" is deemed UNSUBSTANTIATED at this time.

Regarding allegation "Staff did not safeguard resident's personal belongings": Information was reported that the R1's clothes were ruined while living at the facility. Several attempts were made (8/16/2024; 9/25/2024;10/23/24) to gather additional information regarding this allegation however no furnter information was provided during the course of the investigation from the reporting party. Investigation was initiated on 08/07/2024 and interview was conducted with staff and records were reviewed. According to administrator and staff R1's clothing was not ruined by any staff. Administrator stated that R1 had one pants which tore from the waist and administrator had it fixed; a zipper came off from one of R1's jacket and that was taken by family to fix. According to administrator all belongings that were itimized on the Client/Resident Personal Property and Valuables form (LIC621) dated 4/23/2024 were provided to R1's family. Records reviewed revealed that R1's LIC621 prepared and signed by responsible person on 4/25/2022 and 4/23/2024 did not include any of R1's clothing.

Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation "Staff did not safeguard resident's personal belongings" is deemed UNSUBSTANTIATED at this time.

Exit interview held. Copy of report provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2