195850089-6-4-2024-29-AS-KHEN-D6N6YU-20240627211408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850089
Report Date: 06/04/2024
Date Signed: 06/04/2024 01:00:42 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
05/28/2024 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20240528163431

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:	06/04/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Gohar Khachatryan, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not prevent an altercation between residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:25 a.m., the LPA met with Administrator, Gohar Khachatryan and explained the reason for the visit.

At 9:36 a.m., the LPA along with the Administrator conducted a physical plant tour. Between 9:37 a.m. and 10:00 a.m., the LPA conducted interviews with the Administrator, one (1) staff and five (5) residents. At 9:46 a.m., the LPA obtained copies of pertinent documents.

Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

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-20240528163431

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: MARY ELLEN HOMES	FACILITY NUMBER: 195850089
	VISIT DATE: 06/04/2024

NARRATIVE

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Regarding the allegation: Staff did not prevent an altercation between residents. It was alleged that staff did not prevent Resident #1 (R1) from pushing Resident #2 (R2). On 05/24/2024, R1 pushed R2 causing R2 to fall. The Administrator called the paramedics as soon as the caregiver reported R1 and R2’s altercation. R1 is diagnosed with dementia. The Administrator revealed that R1 was admitted to the facility on 05/23/2024 and started to show aggression towards staff once R1’s family left the facility. The Administrator believes that R1’s aggression was due to R1 not being familiar with the facility. The Administrator said that R1 and R2 were separated immediately, and paramedics transported R2 to the hospital. R2 returned to the facility on the same day with no head injuries noted. The Administrator said that she contacted R1’s and R2’s families and physicians. The Administrator explained that R1’s physician adjusted R1’s medication. The Administrator stated that since the altercation, R1 and R2 have not had any other issues or altercations. The Administrator said that R1 has adjusted to the facility and is no longer demonstrating aggressive behavior. During the time of the visit, the LPA conducted interviews with five (5) residents, including R1 and R2. R2 stated that there are no issues between R2 and R1. The interviews with residents revealed that all residents get along with one another and that if there were issues staff intervene to prevent further issues. No concerns were brought up during the resident interviews. Interview with Staff #1 (S1) revealed that S1 immediately reported the altercation to the Administrator and the Administrator called the paramedics. S1 stated that R1 has been happy and hasn’t had anymore altercations with R2. Although R1 pushed R2 while in care, the Administrator and staff did not anticipate R1’s aggression as R1 was newly admitted and was struggling to adjust to the new environment. Additionally, the Administrator and staff reacted appropriately and ensured R1 and R2’s safety. 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 a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC9099 (FAS) - (06/04)

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