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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 03:24:57 PM

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
11/12/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211112142407
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:
11:15 AM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision – Resident #1 (R1) sustained pressure injuries while in care.
Facility retained a resident requiring a higher level of care.
Facility staff is contributing to resident's self-neglect while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 11/15/2021 by LPA Sandra Urena. During today’s visit, LPA Urena met with Diana Makhtesyan, and explained the reason for the visit.

On 11/12/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision which resulted in Resident #1 (R1) sustaining pressure injuries while in care. The complaint allegation was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Dennis Douglas.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
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 9
Control Number 29-AS-20211112142407
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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On 11/15/2021, between 9:00 a.m. and 1:30 p.m., LPA Urena conducted the initial complaint visit. The LPA met with staff Cezar Tolentino at 9:00 a.m. and explained the reason for the visit. Staff Tolentino attempted to contact Administrator Naira Paroyan several times to inform them of the visit; however, the call went directly to voicemail. From 9:25 a.m. to 9:50 a.m., the LPA and Staff Tolentino toured the facility. The LPA obtained and reviewed records from 9:45 a.m. to 11:00 a.m. and conducted interviews from 11:00 a.m. to 1:00 p.m. The LPA determined further investigation was required.

Investigator Douglas attempted to conduct interviews with facility staff, administrator and clients on 12/02/2021, at approximately 11:00am; however, there was no answer at the door. Investigator Douglas then conducted interviews with Witness #1 (W1), a Long-Term Care Ombudsman, and Resident #1 (R1) from approximately 11:20am to 12:15pm; with facility staff and residents on 01/28/2022, at approximately 10:40am; and briefly with facility Administrator on 03/24/2022, at approximately 11:00am. Additionally, Investigator Douglas obtained and reviewed copies of R1’s hospital medical records.

Per the hospital medical report, they indicated that R1 had previously been presented to the hospital ER on 10/28/2021 with complaints of neglect at the facility. The ER noted R1’s urine retention; as a result, a Foley catheter was placed and drained “1700 of dark amber urine”. It was also noted that R1’s lab work indicated ‘leukocytosis of 82 without left shift; Hyponatremia of 109, of 6.6 Hyperkalemia, CO218, GAP18”. At that time, R1 mentioned they had been constipated and advised they did not use self-catheters. R1 advised they had been bed bound and sat in their own urine. It was noted that at the time, R1 was lethargic during the exam but was able to answer questions.

A review of the hospital records indicated that R1 was subsequently transported to the hospital on 11/09/2021 with a history of schizophrenia, panic attack, PTSD, and paraplegia. R1 was brought by ambulance from the facility for a complaint of abdominal pain and vomiting. It was indicated that R1 acknowledged the abdominal pain started sometime in the last seven days after R1 removed their own Foley catheter. R1 stated they had been urinating and were incontinent of urine. The admitting diagnosis contained a varied list of issues; however, a medical report indicated that per a skin assessment performed on R1 “Excoriation (abrasions) from pressure wounds” were observed at the time of admission on 11/09/2021. They were “not stageable”. It was also noted that “bruising on left side with scabs” were observed.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
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: 2 of 9
Control Number 29-AS-20211112142407
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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 While at the hospital, R1 reported the board and care facility where R1 was living was abusing R1, and often allowed R1 to sit in their own urine. APS was notified and it was determined that R1 would not be transferred back to the facility. R1 was discharged to a VA Hospital on 11/30/2021 and treated for Sepsis.

Additional information obtained from hospital W1 indicated that R1 was bedbound and that R1 was a bit of a “problem patient”; could be very defiant when it came to allowing care to be provided for them. R1 refused treatment during the time they were at the hospital and refused treatment at the VA hospital they were transferred to. W1 also indicated they were currently seeking psychiatric care for R1. W1 stated it was observed that R1 developed several skin breakdowns while at the facility. W1 acknowledged the skin breakdown/pressure injuries were not open and explained they appeared to be skin abrasions, red in color. R1 stated the facility staff assured they were properly cleaning R1 prior to admission to the hospital.

R1 was admitted to the facility on 10/13/2021 and was a resident until 11/09/2021. During the course of the investigation, R1 disclosed that they were bed bound and facility staff would leave R1 in room unattended for hours. R1 stated staff would not assist with incontinent needs, bathing, or timely medication administration. R1 also disclosed they developed a blood infection while at the facility. R1 acknowledged developing scabs on back due to laying in their own urine. R1 informed medical staff at the time of hospital admission that they were mistreated and neglected by staff members at the Comfort Elderly Care facility. Although R1 stated that the staff were neglectful, it could also be stated that R1 was refusing care, just as was R1’s behavior at the two hospitals. As a result, it would be the facility’s responsibility to notify R1’s physician and request suggestions for an alternative placement since R1 was refusing assistance from the staff. This may have prevented the skin breakdown.

Per the medical report, it was also verified that per a skin assessment performed on R1 during 11/09/2021 admission, “excoriation (abrasions) from pressure wounds” were observed, non-stageable.

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SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
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: 3 of 9
Control Number 29-AS-20211112142407
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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During the course of the investigation it was revealed that staff members mentioned by R1 (Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) did not have a fingerprint clearance or were not associated to State licensed care facilities by the department in January of 2021. It was also discovered that in November 2021, former staff, S2, admitted they worked at the facility and had no clearance or training to do so. S3 was not associated to the facility until 11/08/2021. This a violation of 87355(e)(1) and will be cited on a separate report.

Based on all the information obtained during the course of the investigation, the allegation of Neglect/Lack of Supervision - Resident #1 (R1) sustained pressure injuries while in care is therefore Substantiated at this time.

Facility retained a resident requiring a higher level of care.

On the allegation, ‘Facility retained a resident requiring a higher level of care’, it is alleged that the facility retained a resident that required a higher level of care than the care that could be provided by staff at the facility.
To investigate this complaint allegation, the LPA interviewed S1 and Staff #2 (S2) about the care provided to Resident #1 (R1). Staff stated that they could not provide the proper care to R1, due to the weight and size of R1; and, that staff was not physically able to assist R1 with daily care needs because R1 was too heavy. Additionally, staff reported that R1 refused care; and consequently, staff did not follow up with the care needed for R1, as indicated in the Physician’s Report. The staff also stated their concern regarding R1’s ‘combative and aggressive’ behavior, which was reported to the administrator; however, nothing was done to address their concern.

The LPA conducted a record review, which revealed that the Physician’s Report stated that R1 required maximum assistance due to several fractures that required the resident to be bedbound. In addition, R1 was not receiving Home Health services.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
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 9
Control Number 29-AS-20211112142407
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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Based on the information gathered through the interviews, and record review, the administrator did not properly assess R1 to determine whether or not the facility staff could actually meet R1’s needs. Although R1 could feed themselves, they needed assistance with all other activities of daily living. Due to R1’s weight and size, the lack of a Hoyer lift and the lack of cooperation by R1 themselves, the staff were unable to meet R1’s needs due to the level of care required for R1. Therefore, the allegation that the facility retained a resident requiring a higher level of care, is deemed SUBSTANTIATED at this time.

Facility staff is contributing to resident's self-neglect while in care.

On the allegation, ‘Facility staff is contributing to resident's self-neglect while in care’, it is alleged that staff contributed to the self-neglect of R1 by not providing the care needed due to the R1’s refusal of assistance. To investigate this allegation, the LPA interviewed staff (S1 and S2). Staff stated that because R1 refused to be touched, the staff did not attend to the needs of the R1. Staff stated that they had noticed a palm size (elongated) redness with white dots on the side of R1’s torso near the hip area. When staff attempted to clean the area, R1 said not to touch it, ‘No it hurts”. Consequently, the red area went untreated. Although R1 didn’t allow staff to help, staff had the responsibility to notify the administrator, R1’s physician and their family members that R1 needed to be reassessed by a medical professional to determine the next course of action.

Based on the information gathered through interviews, and record review, the allegation that the facility staff is contributing to resident's self-neglect while in care’, is deemed SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today. The Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).


Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
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 9
Control Number 29-AS-20211112142407
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
07/29/2022
Section Cited
CCR
1569.312(a)
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1569.312(a) Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2
This requirement is not met as evidenced by:

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Licensee will submit plan to provide proper level of care and supervision to ensure resident needs are met. Submit to CCL by 07/28/2022.
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Based on interviews and records review, the licensee did not comply with the section cited above. Staff failed to assist R1 with incontinent needs, which resulted in abrasions/pressure injuries, which posed an immediate health and safety risk to residents in care

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An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

Type A
06/29/2022
Section Cited
CCR
87466
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87466 – Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical ...weight gains or losses or deterioration of mental …changes are documented and brought to the attention of the resident's physician... This requirement is not met as evidenced by:
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Licensee will submit plan to provide proper level of care and supervision to ensure resident needs are met. Submit to CCL by 07/28/2022.
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Based on the information gathered through the interviews, and record review, the administrator did not properly assess R1 to determine whether or not the facility staff could actually meet R1’s needs, which posed 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: Sandra UrenaTELEPHONE: 747-230-3919
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: 6 of 9
Control Number 29-AS-20211112142407
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
07/29/2022
Section Cited
CCR
87466
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87466 – Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical ...weight gains or losses or deterioration of mental …changes are documented and brought to the attention of the resident's physician... This requirement is not met as evidenced by:
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Licensee will submit plan to provide proper level of care and supervision to ensure resident needs are met. Submit to CCL by 07/28/2022
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Based on the information gathered through interviews, and record review, the allegation that the facility staff is contributing to resident's self-neglect while in care’, which posed 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: Sandra UrenaTELEPHONE: 747-230-3919
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: 7 of 9
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
11/12/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211112142407

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:
11:15 AM
ALLEGATION(S):
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Facility did not ensure that resident was adequately hydrated while in care.
INVESTIGATION FINDINGS:
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This is an amended report. Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 11/15/2021 by LPA Sandra Urena. During today’s visit, LPA Urena met with Diana Makhtesyan, and explained the reason for the visit.


Facility did not ensure that resident was adequately hydrated while in care.
On the allegation, ‘Facility did not ensure that resident was adequately hydrated while in care’, it is alleged that R1 was not being provided water to adequately hydrate.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
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: 8 of 9
Control Number 29-AS-20211112142407
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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To investigate this allegation, the LPA interviewed facility staff (S1 and S2). The interviews revealed that staff would bring glasses of water for R1 at night; and, would bring water to R1 throughout the day. The staff stated that R1 would drink ‘energy drinks’ throughout the day, and would urinate frequently. The LPA asked staff if R1 was consuming the water that the staff would provide? Staff stated that they think R1 consumed the water because the glasses were empty. The LPA conducted a record review, which indicated that R1 arrived at the hospital on 11/09/21 severely dehydrated.

Based on the information gathered through the interviews, and record review, although the resident was admitted to the hospital with a diagnosis of being dehydrated, there is insufficient evidence to support the claim that the facility staff did not ensure that resident was provided with sufficient fluids in order for R1 to obtain the proper hydration while in care. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted, signatures obtained. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
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: 9 of 9