565850522-5-15-2025-29-AS-KHEN-DJ5UXG-20250630155819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850522
Report Date: 05/15/2025
Date Signed: 05/15/2025 02:51:21 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
01/22/2025 and conducted by Evaluator Angela Barutyan

COMPLAINT CONTROL NUMBER: 29-AS-20250122154020

FACILITY NAME:	SELECT SENIOR LIVING IV		FACILITY NUMBER:	565850522
ADMINISTRATOR:	VARNELL, TRACY		FACILITY TYPE:	740
ADDRESS:	128 ERTEN STREET		TELEPHONE:	(805) 777-3855
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	05/15/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Kim Anderson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unqualified staff are administering medications to residents in care.
Staff are administering medication(s) to resident without physician's approval.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 10:45AM. Upon arrival, LPA met with staff and Administrator Kim Anderson. Entrance interview conducted.

During today’s visit, LPA Barutyan conducted a brief physical plant tour upon entry, interviewed two (2) staff between 10:46AM-02:37PM, conducted a medication review for two (2) residents between 10:50AM-11:30AM, and reviewed and obtained copies of pertinent documents between 11:50AM-12:20PM. During the initial visit on 01/29/2025, LPA Z. Chochian conducted staff interviews, reviewed staff/resident records, reviewed the centrally stored medication records for two (2) residents, obtained copies of pertinent documents, and discussed allegations with Kim Anderson.

It was alleged that staff are not receiving medication administration training, and that staff are administering controlled medications. Report Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

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 2

Control Number 29-AS-20250122154020

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: SELECT SENIOR LIVING IV	FACILITY NUMBER: 565850522
	VISIT DATE: 05/15/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA reviewed training records for two (2) staff who administer medications and observed ten (10) hours of medication training upon hire, one (1) hour of hands-on medication orientations conducted monthly, and two (2) hours of medication management conducted by Administrator. Training was in the format of videos, tests/quizzes, and shadowing. All staff handling medications are training certified by Administrator and Licensed Vocational Nurse (LVN) Kim Anderson. Staff are qualified to administer prescription medications, as-needed (PRN) medications, over-the-counter medications, controlled medications, and assist with self-administered medications. Staff interviews confirmed that staff are knowledgeable in medication administration and management. No concerns were noted. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate 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 above allegation “Unqualified staff are administering medications to residents in care” is deemed UNSUBSTANTIATED at this time.

It was further alleged that Staff #1 (S1) administered nonprescription melatonin to Resident #1 (R1) without physician’s or responsible party(ies)’ order/approval. Staff interviewed during the initial visit and today’s visit had no evidence supporting the allegation. LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Record (MAR) for R1 and another resident and observed no documentation of melatonin administration. Medications were centrally stored and locked in the kitchen. All medications and PRNs had physicians’ order on file and PRN authorization letters. Medications were prepared for one (1) day in advance and were properly documented on the CSMDR and MAR. No errors were observed during the medication review. LPA observed that R1 had two (2) prescription medications of Lorazepam 1 mg and Divalproex Sodium 125 mg. Administrator stated that R1 is not administered melatonin as there is no physician’s order and no need because of their prescribed sleep aids. Administrator stated that there is one (1) resident who takes over-the-counter melatonin, and there is physician’s approval. LPA did not observe melatonin stored with R1’s medications. Based on interviews, record review, and medication review the information obtained during the investigation does not have sufficient evidence to corroborate 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 above allegation “Staff are administering medication(s) to resident without physician's approval” is deemed UNSUBSTANTIATED at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2