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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850162
Report Date: 06/29/2022
Date Signed: 06/29/2022 10:48:31 AM

Substantiated


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
02/24/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220224124512
FACILITY NAME:COMFORT ELDERLY CAREFACILITY NUMBER:
195850162
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(818) 602-1622
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 0DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Diana MakhtesyanTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Resident developed a pressure injury while in care
Resident is not being properly positioned while in care
Staff prevent a resident from being mobile while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced today for a subsequent complaint visit to issue findings. The LPA met with Licensee Diana Makhtesyan and explained the reason for the visit.

During the initial visit conducted on 2/25/2022, a file review was conducted at 1:45 p.m., the LPA interviewed staff at 1:42 p.m. and 2:18 p.m., and interviewed residents at 1:37 p.m. and 1:40 p.m. In addition, a physical plant tour was conducted with staff at 3:40 p.m. Interviews were conducted with former staff on 5/16/2022 at 6:15 p.m. and 5/31/2022 at 1:06 p.m. and interviewed Resident #1 (R1) on 6/2/2022 at 2:32 p.m. Home health and hospital records were requested and reviewed.

Regarding the allegation: Resident developed a pressure injury while in care
It was alleged that R1 developed a pressure injury while at this facility. R1 was admitted to this facility on 2/3/2022. Prior to arriving, R1 was recovering in the hospital from a broken ankle, and COVID-19 pneumonia.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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 6
Control Number 29-AS-20220224124512
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 06/29/2022
NARRATIVE
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Records indicated that R1 did not have the presence of any pressure injuries outside of the surgical wound on R1’s right ankle. Upon admission to the facility, R1 was receiving physical therapy, occupational therapy, and nursing visits from a home health agency. As such, R1 was being seen by appropriately skilled professionals on a regular basis. A 2/22/2022 visit from a home health nurse indicated that R1 had a new stage 2 pressure injury on R1’s buttocks. Interviews with R1 and the Administrator supported claims that R1 was not regularly repositioned or moved. Staff claimed that due to R1’s size, it was challenging to reposition R1. R1 was admitted to the hospital on 2/23/2022 and R1 was admitted with a stage 2 pressure injury.

Based on the preponderance of evidence, there is sufficient evidence to support the claim that R1 developed a pressure injury while in care due to lack of care. R1 did not have a pressure injury prior to being admitted to this facility. This allegation is deemed Substantiated at this time.

Regarding the allegation: Resident is not being properly positioned while in care


It was alleged that R1 was not being properly positioned while in care. R1 was admitted to this facility on 2/3/2022. Prior to arriving to the facility, R1 was recovering in the hospital from a broken ankle, and COVID-19 pneumonia. Records indicated that R1 was bedbound. Upon admission to the facility, R1 was receiving physical therapy, occupational therapy, and nursing visits from a home health agency. As such, R1 was being seen by appropriately skilled professionals on a regular basis. Records indicated that although R1 was receiving physical therapy and occupational therapy, yet R1 communicated that outside of the visits from home health, R1 was not repositioned or moved. Interviews supported claims that R1 was not regularly repositioned or moved. Staff claimed that due to R1’s size, it was challenging to reposition R1. There was no mention of staff utilizing a hoyer lift or other supportive device to assist in repositioning R1. Based on the preponderance of evidence, there is sufficient evidence to support the claim that R1 was not being properly positioned while in care. This allegation is deemed Substantiated at this time.

Regarding the allegation: Staff prevent a resident from being mobile while in care
It was alleged that R1 was not helped out of bed or moved around the facility. R1 was admitted to this facility on 2/3/2022. Prior to arriving to the facility, R1 was recovering in the hospital from a broken ankle, and COVID-19 pneumonia. Records indicated that R1 was bedbound. Upon admission to the facility, R1 was receiving physical therapy, occupational therapy, and nursing visits from a home health agency. As such, R1 was being seen by appropriately skilled professionals on a regular basis.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20220224124512
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 06/29/2022
NARRATIVE
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 Records indicated that R1 was receiving physical therapy and occupational therapy, yet R1 communicated that outside of the visits from home health, R1 was not repositioned or moves. Interviews with R1 and the Administrator supported claims that R1 was not regularly repositioned or moved. R1 claimed that the staff always ‘changed’ and outside of providing R1 with food, they were not taken out of their bed nor did staff assist with exercises. The Administrator admitted that R1 was not moved from the bed because it was ‘too hard’ to move R1 due to their size and broken bones, which was why R1 was not moved out of bed. There was no mention of staff utilizing a hoyer lift or other supportive device to assist in repositioning R1.

Based on the preponderance of evidence, there is sufficient evidence to support the claim that staff prevented a resident from being mobile while in care. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's reports and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220224124512
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Review Regulation 87468.1, 87468.2 and submit a Statement of Understanding, detailing how the licensee plans to maintain voluntary compliance. Submit statement no later than 7/1/2022.
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Based on interview and record review, the licensee did not comply with the section cited above, as R1's care needs were not met regarding repositioning, moving R1, or preventing the development of pressure injuries, which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/24/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220224124512

FACILITY NAME:COMFORT ELDERLY CAREFACILITY NUMBER:
195850162
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(818) 602-1622
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Diana MakhtesyanTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff are not properly trained on how to use Bipap device
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced today for a subsequent complaint visit to issue findings. The LPA met with Licensee Diana Makhtesyan and explained the reason for the visit.

During the initial visit conducted on 2/25/2022, a file review was conducted at 1:45 p.m., the LPA interviewed staff at 1:42 p.m. and 2:18 p.m., and interviewed residents at 1:37 p.m. and 1:40 p.m. In addition, a physical plant tour was conducted with staff at 3:40 p.m. Interviews were conducted with former staff on 5/16/2022 at 6:15 p.m. and 5/31/2022 at 1:06 p.m. and interviewed Resident #1 (R1) on 6/2/2022 at 2:32 p.m. Home health and hospital records were requested and reviewed.

CONT 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220224124512
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 06/29/2022
NARRATIVE
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Regarding the allegation: Staff are not properly trained on how to use Bipap device

It was alleged that staff did not know how to use Resident #1’s (R1) Bipap machine, as R1 said they were not using it at night. A review of medical records revealed that R1 required usage of the bipap machine at least eight (8) hours a night, yet it was also documented that R1 was non-compliant in using the machine frequently. Further review of hospital records noted that at times, R1 refused to use the bipap machine due to respiratory distress. Whereas staff interviews revealed that staff received minimal training from the licensee, there was insufficient evidence obtained regarding the above-mentioned claim as the Administrator claimed that staff assisted R1 with the machine and were familiar with it. A review of home health records revealed that staff were trained on several aspects of R1’s care, yet the specifics of a bipap machine was not specified. Based on the availability of evidence, there is insufficient evidence to support the claim that staff were not properly trained on how to use a bipap machine. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6