195850163-3-23-2023-29-AS-JAPL-CSBND8-20230530102154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850163
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:01:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
03/20/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230320143742

FACILITY NAME:	BELLAIRE SENIOR CARE, LLC		FACILITY NUMBER:	195850163
ADMINISTRATOR:	ELEN KIRAKOSYAN		FACILITY TYPE:	740
ADDRESS:	6523 BALLAIRE AVE		TELEPHONE:	(818) 856-6980
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 5	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Ovsanna Khayalan, House Manager		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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1. Staff not providing adequate supervision resulting in resident eloping.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and was let into the home by Venera Nesterova, Staff. Ovsanna Khayalyan, House Manager was contacted by staff via telelphone and she arrived at 9:08am to conduct the visit. Ellen Kirakosyan, was not available to conduct the visit. The reason for today's visit was explained.

On today's visit, LPA Yee conducted interviews with the House Manage at 9:15am, Staff #1 at 11:40am, Witness #1 at 10:14am and reviewed resident files at 9:46am and toured the facility at 11:55am.

Per information obtained from interviews conducted during the investigation, Resident #1
Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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-20230320143742

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAIRE SENIOR CARE, LLC	FACILITY NUMBER: 195850163
	VISIT DATE: 03/23/2023

NARRATIVE

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was accepted for placement at the home by Davit Hakobyan, Licensee. On the evening of 3/16/23, Resident #1 was transported from the hospital to the home. Staff #1 was contacted by the Licensee via telephone around 8:30pm and was told that the vehicle dropping off the new resident, Resident #1, was outside and to open the gate and also to prepare the bedroom. Per the House Manager, the Licensee did not tell anyone about the new placement. Resident #1 entered the home and was very active and went around saying hello to all the residents before sitting down in the arm chair in the living room. Staff #1 enquired if Resident #1 had eaten and the response was yes. Resident #1 also informed Staff #1 that they did not want to be here and wanted to go home to Santa Monica. Resident #1 was informed that the home was in North Hollywood.
Per Staff #1, Resident #2 needed a diaper change and Resident #1 was left sitting in the armchair while diaper was being changed. Staff #1 had stepped away and upon return did not see Resident #1 in the living room. Staff #1 took off running outside to locate Resident #1 and ran all the way to Victory Blvd, while calling the Licensee. Licensee sent over Staff #2, who checked out the facility perimeters and called 911 and four police cars responded. The police walked and drove around to locate Resident #1 and was unsuccessful. The search was terminated around 4am. Staff #1 was notified by Staff #2, via telephone around 10am the following morning that Resident #1 had been found and was at the hospital. Resident #1 has been relocated to another home.

Per tour of the facility and inspection of the external doors located in the living room, kitchen and the back bedroom identified as Bedroom #1, the installed auditory devices were not operational. The home serves dementia residents. This resulted in Resident #1 being able to leave the home without Staff #1's knowledge within 20-30 minutes after moving into the facility.
Based on the information obtained on today's visit, the above allegation is SUBSTANTIATED.
Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8.
Exit interview was conducted, Appeals Rights discussed and a copy of report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230320143742

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAIRE SENIOR CARE, LLC	FACILITY NUMBER: 195850163
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/27/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services:A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs.	1 2 3 4 5 6 7	Licensee shall ensure that the residents are properly assessed and have the appropriate number of staff per shift prior to accepting a resident Licensee will submit a signed written statement that the Section 87464
	8 9 10 11 12 13 14	as identified in the pre-admission appraisal specified in Section 87457, This requirement was not met as evidenced by:Appropriate supervision was not provided, Resident #1 was able to elope from the facility	8 9 10 11 12 13 14	was read, understood and will be complied with at all times. Provide POC by 3/24/23. Resident #1 is no longer at the home
Type A 03/24/2023 Section Cited CCR 87705(j)	1 2 3 4 5 6 7	Care of Persons with Dementia:The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as	1 2 3 4 5 6 7	The Licensee will replace all the auditory devices and provide evidence that the correction has been made. Licensee will provide a signed written statement that all the auditory devices are working and monthly
	8 9 10 11 12 13 14	observed during tour of home. The auditory devices on all the external doors were not operational	8 9 10 11 12 13 14	checks will be conducted by3/24/23

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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