Complaint Investigation Report

197609023-9-30-2022-31-AS-MVAO-CKSTNC-20221102145232

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 21731 VENTURA BLVD., STE. 250

This is an official report of an unannounced visit/investigation of a complaint received in our office on

09/30/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220930103850

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.

It is alleged that staff gave resident #1 (R1) another resident's (R2) medication.

LPA conducted an interview with licensee Mubeen Naimuddin regarding the allegation. Information interview revealed that R1 was given another resident's medication on accident by staff #1 (S1) on 9/27/22 in the evening. 911 was called and R1 was taken to West Hills Emergency Room and is still currently hospitalized. LPA obtained a copy of R1's physician report, medication list, and R2's medication list. Based on the information obtained through interview this allegation is deemed Substantiated. Deficiency cited on LIC 9099D. Appeal Rights explained.

A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Appeal Rights explained. Exit Interview conducted.