195850068-8-6-2021-29-AS-DPEA-C82STR-20211022140955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850068
Report Date: 08/06/2021
Date Signed: 08/06/2021 11:57:10 AM

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
11/17/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20201117144457

FACILITY NAME:	BELLAIRE SENIOR CARE LLC		FACILITY NUMBER:	195850068
ADMINISTRATOR:	BURSALYAN, KARPIS		FACILITY TYPE:	740
ADDRESS:	6523 BELLAIRE AVE		TELEPHONE:	(818) 688-1315
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	0	CENSUS: 0	DATE:	08/06/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Oganes J Duymlyan - House Manager		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff member hit resident with an object
Resident's hygiene needs are not being met

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. LPA met with Oganes J Duymlyan and explained the reason for the visit. LPA spoke with Administrator who stated Oganes can sign for the report.

During the course of the investigation, LPA conducted a physical plant tour virtually on 11/19/2020 as well as interviewed Administrator. On 7/27/21 LPA conducted interviews with facility staff and residents and gathered and reviewed facility documentation pertinent to the allegation.
It was alleged that staff member hit resident with an object, LPA interview with (5) residents and staff revealed that no one has ever witnessed any staff member hit a resident with an object. All residents did not express any concerns for their health and safety while in the care of this facility at this time. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff member hit resident with an object. Therefore, the above allegation is UNSUBSTANTIATED at this time.
(continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

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-20201117144457

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: BELLAIRE SENIOR CARE LLC	FACILITY NUMBER: 195850068
	VISIT DATE: 08/06/2021

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

(Continued from 9099)

It was alleged that Resident’s hygiene needs are not being met, LPA interviews with (5) residents revealed that they had no concerns about staff assistance with hygiene or toileting needs. Residents also stated they get bathed at least twice a week and staff typically check in on them every hour. Most residents stated that Staff are typically timely with toileting assistance when requested to do so. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that resident’s hygiene needs are not being met. Therefore, the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via Email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2