195850178-12-31-2024-29-AS-KHEN-DCH2N2-20241231163200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850178
Report Date: 12/31/2024
Date Signed: 12/31/2024 10:35:39 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/02/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230802154022

FACILITY NAME:	MONOGRAM VILLA		FACILITY NUMBER:	195850178
ADMINISTRATOR:	KRBASHYAN, AZNIV ANGELA		FACILITY TYPE:	740
ADDRESS:	5536 TYRONE AVE		TELEPHONE:	(818) 808-7792
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	12/31/2024
		UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Angela Azniv Krbashyan		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee is retaliating against residents authorized representative.
Staff failed to assist resident with oral hygiene per physician orders.
Licensee did not provide resident's authorized person copies of requested records.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 9:59 a.m., the LPA met with the Administrator, Angela Azniv Krbashyan and explained the reason for the visit.

During the initial visit conducted on 8/4/2023 between 10:10 a.m. and 2:30 p.m., LPA Peraldi conducted a physical plant tour and conducted interviews with the Administrator, one (1) resident and one (1) staff. During the initial visit, the LPA reviewed records and obtained copies of pertinent documents.

Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

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 2

Control Number 29-AS-20230802154022

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MONOGRAM VILLA	FACILITY NUMBER: 195850178
	VISIT DATE: 12/31/2024

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

Regarding the allegation: Licensee is retaliating against residents authorized representative. It was alleged that the Licensee is retaliating against Resident #1’s (R1’s) authorized representative by changing the Wifi password and not giving R1’s authorized representative the updated Wifi password. The Administrator stated that she does provide the Wifi password if requested. The LPA advised the Administrator and R1’s authorized representative that they need to communicate properly with one another without arguing. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff failed to assist resident with oral hygiene per physician orders. It was alleged that staff did not follow R1’s oral hygiene per physician orders. Per record review conducted on 8/4/2023, R1 did not have a physician order for an oral hygiene routine. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Licensee did not provide resident's authorized person copies of requested records. It was alleged that the Licensee did not provide R1’s authorized representative copies of R1’s records such as the needs and service plan. Interview conducted with the Administrator revealed that the Administrator provides copies of all resident records upon admission and as requested. The LPA received conflicting information throughout the course of the investigation. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2