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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610053
Report Date: 09/14/2024
Date Signed: 09/14/2024 02:16:27 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
08/29/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240829160224
FACILITY NAME:BELLA NOVA VILLA IIFACILITY NUMBER:
567610053
ADMINISTRATOR:AYALA, MARIA S.FACILITY TYPE:
740
ADDRESS:1720 CORONADO PLACETELEPHONE:
(805) 242-6682
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 5DATE:
09/14/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria AyalaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff does not properly discard deceased residents medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with Administrator Maria Ayala and explained the reason for the visit.

On 09/06/24, between 10:15 a.m. and 5:30 p.m., the LPA conducted a tour of the facility, conducted a file review and a medication audit. During today's visit the LPA conducted three (3) staff interviews, three (3) interviews with residents family members and a medication audit.

Report will continue on LIC9099-C (2nd Page).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
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 6
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
08/29/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240829160224

FACILITY NAME:BELLA NOVA VILLA IIFACILITY NUMBER:
567610053
ADMINISTRATOR:AYALA, MARIA S.FACILITY TYPE:
740
ADDRESS:1720 CORONADO PLACETELEPHONE:
(805) 242-6682
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 6DATE:
09/14/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria AyalaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff does not refill residents medication in a timely manner.
Staff mismanaged residents medication.
Staff does not ensure that an adequate food supply is maintained on premises.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with Administrator Maria Ayala and explained the reason for the visit.

On 09/06/24, between 10:15 a.m. and 5:30 p.m., the LPA conducted a tour of the facility, conducted a file review and a medication audit. During today's visit the LPA conducted three (3) staff interiews, three (3) interviews with resident's family members and a medication audit.

Report will continue on LIC9099-C (2nd Page).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20240829160224
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: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
VISIT DATE: 09/14/2024
NARRATIVE
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On the allegation "Staff does not refill residents medication in a timely manner"; it is the concern of the reporting party that Staff #1 does not refill the residents medication in a timely manner. To investigate the allegation the LPA conducted a medication audit for four (4) out six (6) residents, observations and interviews. During the medication audits the LPA observed all prescribed medications to be filled, and the administrator informed the LPA that a refill had already been submitted for the medications with low quantities, such as a resident #2's (R2's) Haloperidol. During today's visit the LPA observed R2's Haloperidol medication being delivered. Staff interviews revealed that when the residents have about 10 days left on medications they will notify the administrator, so the administrator can get the medications refilled, and that the resident have not gone without medications due to them not being refilled in a timely manner. Staff interviews also revealed that a Hospice nurse comes twice a week and they let the nurse know every time a resident needs a refill. The Administrator stated that they have never run out of medications, and that if they are ever very low on any medication they would place a STAT order with the hospice nurse or resident's physician and get a same day order delivered. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time.

On the allegation "Staff mismanaged residents medication"; it is the concern of the reporting party that Staff #1 (S1) administers medication (Lorazepam and Haloperidol) to residents that are not prescribed to them. It was further reported that if a resident is feeling agitated and S1 does not have the medication prescribed to them, S1 would use another residents medication. To investigate the allegation the LPA conducted observations, medication audit, and interviews. On 09/06/24, when a resident was agitated the LPA observed staff provide medication to the resident. The LPA verified that it was the resident's prescribed medication, and correct time to provide. Medication audit conducted on 09/14/24 revealed that only two (2) residents take lorazepam, one (1) resident takes haloperidol. The medication was centrally stored and documented on the Centrally Stored Medication and Destruction Record (CSMDR) and there was nothing observed to suggest that their medications are being provided to other residents. Staff interviews revealed that they have never seen S1 administer medications to residents that are not prescribed to them. In addtion, S1 denied ever giving residents medications that were not prescribed to them. Furthermore, interviews with residents family members revealed that they have no concerns regarding the residents medications. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time.
Report will continue on LIC9099-C (3rd page).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240829160224
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: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
VISIT DATE: 09/14/2024
NARRATIVE
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On the allegation "Staff does not ensure that an adequate food supply is maintained on premises"; it is the concern of the reporting party that 2-3 weeks have gone by where there is no groceries or wipes for residents. It was further reported that staff members would purchase or sometimes order take out and that the residents complain they’re hungry. To investigate the allegation the LPA conducted a plant tour and interviews. On 09/06/24 and during today's visit, the LPA observed a sufficient amount of perishable and non-perishable food at the facility. The LPA also observed that snacks such as fruit and beverages were available for the residents. When the LPA arrived during today's visit the LPA observed three (3) residents at the kitchen table that had just finished eating breakfast. The LPA observed staff asking the the residents if they wanted any additional food, and provided cookies. In addition, during today's visit, the LPA observed staff cook and provide a squash side dish, paired with a macaroni and corn salad, and a taco from taco bell for lunch. Staff encouraged the residents to eat, and continue to offer other options. Staff interviews revealed that they always have food at the facility and the residents are not left hungry. If there are ever running low on supplies staff will notify the administrator, and they provide a list of things that are needed to the administrator every Monday and Friday. The administrator stated that the residents are never left hungry, and they are provided a variety of food. They went on to state that they order take out once a week, usually on Saturday's for lunch to give the resident's more variety in their food, but always pair it with vegetables and fruits to make it a balanced meal. Furthermore, all interviews conducted with residents family members revealed that they visit the residents once a week, and they have no concerns with the care being provided by the staff, and are very satisfy with the care provided including the meals. One of the family members revealed that they are pleased that the residents get fresh food, and have no concerns residents are being left hungry Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20240829160224
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: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
VISIT DATE: 09/14/2024
NARRATIVE
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On the allegation "Staff does not properly discard deceased residents medication."; it is the concern of the reporting party that when residents pass away staff #1 (S1) would not properly discard the medication and saves the medication in boxes. To investigate the allegation the LPA conducted a medication audit on 09/06/24. During the medication audit, the LPA observed four (4) different medications that were prescribed to a resident (R1) that had passed away on 08/07/2024 stored in a locked night-stand in the garage. The medication was among other extra medications for current residents, that had not been administered or discontinued. Upon observation, S1 stated that they were not aware that the medication for R1 was there and did not know what to do with the medication. Based on observation the allegation that Staff does not properly discard deceased residents medication is Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).Exit interview conducted. Today's reports and appeal rights were reviewed and issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240829160224
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: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2024
Section Cited
CCR
87465(i)
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87465(i) Prescription medications which are not taken with the resident upon termination of services,not returned to the issuing pharmacy, ...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident...
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Administrator agress that by 09/17/24 they will submit a statement of understanding that they reviewed the regulation and confirm medications awaiting destruction have been destroyed.
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This requirement is not met as evidenced by: Based on observations, interview, the licensee did not comply with the section cited above by not disposing or returning to issuing pharmacy Resident's medication who passed away, which poses a potential health and safety risk to residents in care.
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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: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6