195850163-11-23-2021-29-AS-JAPL-CATUW7-20220119145612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850163
Report Date: 11/23/2021
Date Signed: 11/23/2021 12:55:50 PM

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
08/16/2021 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20210816113039

FACILITY NAME:	BELLAIRE SENIOR CARE, LLC		FACILITY NUMBER:	195850163
ADMINISTRATOR:	HAKOBYAN, DAVIT		FACILITY TYPE:	740
ADDRESS:	6523 BALLAIRE AVE		TELEPHONE:	(818) 516-8819
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	11/23/2021
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Sandy Khambekyan, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff not providing residents medication as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegation. The LPA met with administrator Sandy Khambekyan at 9:41 a.m., and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour at 8:53 a.m., to ensure there are no health and safety hazards.

On 08/23/2021, LPA Walker subpoenaed Medical Records for Resident #1 (R1).
On 08/24/2021, LPAs Salia Walker and Ashley Smith conducted an initial complaint visit. The LPAs conducted a physical plant tour at 09:12 a.m. Between 09:59 a.m. and 10:10 a.m., the LPAs conducted interviews with five (5) out of six (6) residents. Between 08:56 a.m. and 11:22 a.m., the LPAs conducted interviews with four (4) staff. At 10:51 a.m., the LPAs reviewed records and obtained copies of records pertinent to the investigation. The LPAs determined, at that time, that further investigation was required.

Continue on LIC9099C..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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 3

Control Number 29-AS-20210816113039

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: BELLAIRE SENIOR CARE, LLC	FACILITY NUMBER: 195850163
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/29/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5) Incidental Medical and Dental Care:(a)A plan for incidental medical.. care shall be developed by each facility.. by compliance with the following:(5)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee has agreed to do the following: 1. Submit a Plan of Action on steps the facility will be taking to prevent any future medication errors. 2. Submit a completed in-service medications training on section 87465 to LPA by 11/29/21.
	8 9 10 11 12 13 14	Based on Record review, Interviews, and medication review, the licensee did not comply with the section cited above, as R1’s medication was not discontinued per physician’s orders that lead to hospitalization, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210816113039

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: BELLAIRE SENIOR CARE, LLC	FACILITY NUMBER: 195850163
	VISIT DATE: 11/23/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 09/08/2021, LPA Walker received R1’s Medical Record and conducted a review of the records.

Regarding the allegation, ‘Staff not providing residents medication as prescribed,’ the complainant’s concern is that Resident #1 (R1) was hospitalized for high levels of medication toxicity. The complainant was also concerned that R1 had an altered mental status upon being hospitalized.

During the investigation, LPAs Walker and Smith reviewed records, interviewed staff, and residents. The record review revealed that R1 has a history of hospitalization for high levels of medication toxicity. The records also revealed that there were orders from a physician advising for R1 to discontinue medication due to the adverse reaction.

An interview conducted with R1 revealed that the medication was not discontinued, as R1 stated that staff assisted R1 with the self-administration of the medication, even though it was ordered to be discontinued, on the morning of 08/24/2021.

Interviews with staff revealed that staff assisted in the self-administration of medications on the morning of 08/24/2021, for six (6) out of six (6) residents, including R1’s medication that was ordered to be discontinued. Interviews with the Licensee also revealed that the Licensee had no knowledge of the order to discontinue R1’s medication; and, the facility did not have a Centrally Stored Medication log to reflect accuracy.

Based on records reviewed, the interview with R1, interviews with the staff, and interviews with the Licensee representative, there is sufficient evidence to support the allegation ‘Staff not providing residents medication as prescribed.’ Therefore, this allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 9099D).
Exit interview conducted, a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3