195850163-10-24-2022-29-AS-JAPL-CKN3ZQ-20221028184156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850163
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:50:39 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
10/17/2022 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20221017131711

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: 6	DATE:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ovsanna Khayalyan		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Licensee is not assisting resident with arranging transportation for medical care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10 day visit. The LPA met with staff Venera Nesterova and explained the reason for the visit. House Manager Ovsanna Khayalyan arrived shortly thereafter.

Today, the LPA conducted a physical plant tour at 9:25 a.m., interviewed staff at 9:30 a.m., 10:10 a.m., and 10:56 a.m.; interviewed residents at 9:51 a.m., 9:57 a.m., 10:00 a.m., and 10:05 a.m.; interviewed a representative from Resident #1 (R1)'s dialysis treatment center at 10:45 a.m.; and, reviewed documents.

CONT 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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-20221017131711

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: 10/24/2022

NARRATIVE

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Regarding the allegation, it was alleged that the licensee is not assisting resident with arranging transportation for medical care. Interviews confirmed that Resident #1 (R1) was admitted to this facility approximately 09/30/2022. Staff interviews and interviews with a representative from the dialysis treatment center that R1 attends confirmed that R1 had missed a few appointments due to transportation challenges. The dialysis treatment center confirmed that R1 missed dialysis on 10/01/2022 and 10/13/2022. Staff communicated that they understand their responsibility in assisting R1 with arranging transportation should an error occur. There was no additional follow-up between staff, Access transportation, or the dialysis treatment center regarding R1's missed appointment. Whereas it was alleged that the licensee communicated that it was 'not their job' to assist R1 with transportation, a records review confirmed that this was said by the owner of the facility that R1 resided in prior to coming to this facility.

Based on the information obtained, there is sufficient evidence to support the claim that the licensee failed to assist resident with arranging transportation for medical care. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the California Code of Regulations, deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, and appeal rights discussed. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221017131711

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: 10/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2022 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465(a)(2) Incidental Medical and Dental Care. The licensee shall provide assistance in meeting necessary medical and dental needs ... In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Have staff review the transportation protocol as described in the Plan of Operation. Have staff sign off that they have reviewed the protocol. Submit sign-in sheet to CCL no later than 10/26/2022.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above, as R1 missed dialysis treatments in the past, 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: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

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