195850128-2-24-2022-29-AS-JAPL-CCR8NN-20220321224012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850128
Report Date: 02/24/2022
Date Signed: 02/24/2022 09:44:33 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
06/02/2021 and conducted by Evaluator Salia Walker

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210602122148

FACILITY NAME:	NO HO RESIDENTIAL CARE, INC.		FACILITY NUMBER:	195850128
ADMINISTRATOR:	DURGARYAN, REBEKA		FACILITY TYPE:	740
ADDRESS:	6605 AGNES AVENUE		TELEPHONE:	(818) 404-0290
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 5	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Rebeka Durgaryan, Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Salia Walker conducted a subsequent complaint visit to deliver findings for the above allegation. The initial complaint visit was conducted on 06/03/2021 by LPAs Salia Walker and Brian Balisi. During today’s visit, LPA Walker met with Administrator Rebeka Durgaryan at 9:10 a.m., and explained the reason for the visit.

On 06/02/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was noted that Resident #1 (R1) was hospitalized with extensive injuries which included a humerus fracture to left shoulder due to an assault by R1’s roommate, Resident #2 (R2). R2 also assaulted additional residents causing injury which required medical attention. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Laura Garcia.

Continue on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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-20210602122148

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: NO HO RESIDENTIAL CARE, INC.	FACILITY NUMBER: 195850128
	VISIT DATE: 02/24/2022

NARRATIVE

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On 06/02/2021, at 9:00am, LPAs Walker and Balisi conducted the initial complaint visit and met with Rebeka Durgaryan, Administrator. Between 9:00am and 11:30am, the LPAs toured the facility with the Administrator, reviewed and obtained copies of records pertinent to the investigation. The LPAs informed the Administrator that the complaint allegation required further investigation.

Investigator Garcia conducted interviews with the Administrator on 07/15/2021, at approximately 10:18am and on 09/16/2021, at approximately 12:30pm; with facility staff on 07/15/2021, at approximately 11:00am, on 09/17/2021, at approximately 2:00pm, and on 09/18/2021, at approximately 1:00pm; ; with residents on 09/17/21, from approximately 1:30pm to 2:30pm; and with Resident #3 (R3) responsible party on 10/18/2021, at approximately 11:00am. Investigator Garcia was unable to interview R2 and Resident #4 (R4) due to unable to locate R2’s current placement and R4’s diagnosis of dementia. Investigator Garcia also obtained and reviewed Incident reports, facility records, Los Angeles Police Department (LAPD) Investigative Report, and Kaiser medical records.

Information obtained from interviews, incident reports, police reports and medical records, revealed that on 05/30/21 at approximately 12:45am, R2 began assaulting staff and residents by breaking and throwing large blunt objects including furniture and a wheelchair. Staff attempted to intervene and called 911. R2 fled the scene and later returned to the facility. R2 stated to police that an argument had taken place with R1, which prompted R2 to throw an unknown object at R1. R2 told the officers that R2 “blacked out” and when the blackout episode was over, R2 ran out of the facility. R2 was arrested for assault with a deadly weapon and transported to the Hollywood station for processing. R1 sustained extensive injuries including a proximal humeral head fracture to the left shoulder, multiple abrasions, lacerations, traumatic head injury, and was transported to Kaiser Hospital. R3 suffered bruising and a half inch laceration above left eye which required first aid treatment. R4 sustained a nasal fracture and was transported to the hospital. Staff #1 (S1) sustained a laceration to nose and bruising to hand caused by R2 throwing a chair at S1’s head.

Continue on LIC9099C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210602122148

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: NO HO RESIDENTIAL CARE, INC.	FACILITY NUMBER: 195850128
	VISIT DATE: 02/24/2022

NARRATIVE

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On the allegation, Neglect/Lack of Care and Supervision - Resident #1 (R1) sustained unexplained injuries while in care: The information Investigator Garcia obtained through interviews with R1, residents at the facility, staff members, and review of the police and medical records found that there was insufficient evidence to determine neglect/lack of supervision by the staff. R1 denied any type of neglect/lack of supervision on behalf of S1 that was caring for residents at the time of the incident on 05/30/2021. R1 stated that S1 immediately intervened in order to protect the residents and attempted numerous times to stop R2 from additional attacks. S1 immediately dialed 911 and provided first aid. According to the police report, officers determined that R2 suffered from a medical emergency/black outs while R2 assaulted the residents. Additionally, upon detaining R2, R2 appeared disoriented and confused. Based on the information and documentation provided, Investigator Garcia determined there was not sufficient evidence to support the above allegation. Therefore, the allegation of neglect/lack of care and supervision is deemed Unsubstantiated at this time.

Exit interview, copy of report given.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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