195850089-8-18-2023-29-AS-KHEN-CUYSEW-20230823134924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850089
Report Date: 08/17/2023
Date Signed: 08/18/2023 07:52:46 AM

Unsubstantiated

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
05/05/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230505112637

FACILITY NAME:	MARY ELLEN HOMES		FACILITY NUMBER:	195850089
ADMINISTRATOR:	KHACHATRYAN, GOHAR		FACILITY TYPE:	740
ADDRESS:	7752 MARY ELLEN AVENUE		TELEPHONE:	(818) 279-1415
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 6	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	04:34 PM
MET WITH:	Gohar Khachatryan		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Sexual Abuse – Staff inappropriately touched resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the allegation listed above. LPA Urena spoke with Administrator Gohar Kachatryan on the phone, and explained the reason for the visit. LPA Urena read the report otp the administrator over the phone. The administrator agrred to allow staff signed the report.

On 05/05/2023, the Department received a complaint regarding an allegation of Sexual Abuse. It was alleged that on 04/28/2023, at approximately 11:00am, facility Staff #1 (S1) inappropriately touched Resident #1 (R 1) during a shower. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Peter Zertuche.

Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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-20230505112637

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: MARY ELLEN HOMES	FACILITY NUMBER: 195850089
	VISIT DATE: 08/17/2023

NARRATIVE

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P.2
On 05/09/2023, from 1:00pm to 2:30pm, Licensing Program Analyst (LPA) Sandra Urena conducted an initial visit to investigate the allegation listed above. LPA Urena met with the Administrator Gohar Khachatryan and explained the reason for the visit. At 1:15pm, the LPA requested documents pertinent to the investigation and interviewed the Administrator at 1:30pm. The LPA requested the personnel file for Staff #1 (S1). The Administrator stated that S1 was not background cleared, nor associated to the facility. The LPA issued a citation and an immediate civil penalty of $500 during the visit due to S1 not being fingerprint cleared and associated to the facility. The Administrator stated that they hired S1 approximately 05/01/2022 to assist residents with showers. S1 was last present at the facility the morning of 05/09/2023. The LPA determined the complaint allegation required further investigation prior to issuing findings.

On 05/10/2023, at approximately 2:00pm, Investigator Zertuche conducted a visit to the Los Angeles Police Department to obtain information on their case. Investigator Zertuche was informed there was no record of the incident or service calls to the facility. On 05/10/2023, from approximately 2:30pm to 3:45pm, Investigator Zertuche conducted interviews with the facility Administrator, R1, residents, and staff; on 05/25/2023, from approximately 8:30am to 9:30am, with a resident, and S1; on 06/21/2023, at approximately 8:30am with the Ombudsman, who informed the investigator that no information could be released without R1’s consent. Investigator Zertuche made numerous attempts to contact the complainant and R1’s resident representative, but return calls were not received and interviews were unable to be conducted. In addition, Investigator Zertuche reviewed R1’s facility file documents and staff member statements.

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SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230505112637

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: MARY ELLEN HOMES	FACILITY NUMBER: 195850089
	VISIT DATE: 08/17/2023

NARRATIVE

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Pg.3
A review of R1’s Physician Report, dated 02/04/2022, lists R1 as non-ambulatory, with mild cognitive impairment. Records indicate R1 can bathe and groom self with adaptive equipment needed. R1 has a history of CVA in 2001 which resulted in left sided weakness. R1’s preplacement appraisal information, dated 02/04/2022, includes R1 needs assistance with bathing, hair care and personal hygiene.

The investigation revealed, on 04/28/2023 at 11:00am, R1 felt uncomfortable during a shower with S1’s assistance stating S1 cleaned R1’s private areas with S1’s hand instead of using a washcloth as usual. R1 stated S1 was wearing gloves while S1 put soap on S1’s hand and then wiped R1’s vagina back and forth a couple of times. S1 denied the allegation stating they provided R1 with a washcloth and R1 cleaned their own private areas.

There were no witnesses to the incident and all other residents denied inappropriate behaviors by S1. Facility staff members reported no inappropriate behaviors and stated R1 had a history of making similar allegations. There was no police investigation or doctor visit for the alleged incident. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore the allegation “Sexual Abuse – Staff inappropriately touched resident” is deemed Unsubstantiated at this time.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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