567610056-1-16-2025-29-AS-KHEN-DE8QKS-20250225111449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610056
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:36:21 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
01/13/2025 and conducted by Evaluator Angela Barutyan

COMPLAINT CONTROL NUMBER: 29-AS-20250113113032

FACILITY NAME:	APPLEGATE @ BERKSHIRE		FACILITY NUMBER:	567610056
ADMINISTRATOR:	ALVAREZ, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	2010 FULLBROKE DRIVE		TELEPHONE:	(805) 870-4400
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	6	CENSUS: 6	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	Irma Carmona		TIME COMPLETED:	01:45 PM

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 10:32AM. LPA initially met with facility staff. Licensee Irma Carmona arrived shortly after the visit began. Entrance interview conducted.

During today's visit, LPA interviewed two (2) staff members beginning at 10:33AM, interviewed Licensee, conducted a medication review for two (2) residents at 10:55AM, reviewed records and obtained copies of pertinent documents, and interviewed residents beginning at 11:39AM. 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 three (3) 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: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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-20250113113032

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 @ BERKSHIRE	FACILITY NUMBER: 567610056
	VISIT DATE: 01/16/2025

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. One (1) staff file for Staff #1 (S1) observed was missing 20 hours annual training and was cited on a Case Management – Deficiencies visit during today’s visit. However, S1 does not handle or prepare medications. Interviews with staff, Licensee, and residents confirmed that S1 does not administer or prepare medications. LPA observed the remaining two (2) staff files to be complete and have no missing documents or trainings. 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. LPA observed the MAR forms for two (2) residents with last documented medication administered yesterday 01/15/2025 at 05:00PM. 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 "Staff are mismanaging residents' medication" is deemed Unsubstantiated at this time.

Licensee was unable to stay for the remainder of the visit and designated staff Patrick Sangalang to sign the report.

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: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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