195850179-8-5-2025-29-AS-KHEN-DKZV4M-20250829160635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850179
Report Date: 08/05/2025
Date Signed: 08/05/2025 11:27:13 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
08/27/2024 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20240827151722

FACILITY NAME:	YMZ ASSISTED LIVING		FACILITY NUMBER:	195850179
ADMINISTRATOR:	DURGARYAN, REBEKA		FACILITY TYPE:	740
ADDRESS:	6206 KLUMP AVENUE		TELEPHONE:	(818) 358-2955
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2025
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Naira Aghajanyan, Designated Staff		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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1. Staff neglect resulted in R1's death
2. Staff did not seek timely medical attention for a resident
4. Staff did not meet R1's care needs
5. Staff is unable to communicate effectively
6. Staff is not properly trained and unqualified to care for residents
8. Staff did not have planned activities for the residents
9. Staff made unauthorized medical decisions for the residents
11. Staff mishandled a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Yee conducted another subsequent complaint visit to deliver the findings of the investigation for the above allegations. LPA Yee was let into the home by Crystal McKie, Staff. Rebeka Durgaryan, Administrator, was contacted by LPA at 10:05am, to advise her of today's visit and was informed that she was on a mini vacation and Naira Aghajanyan, Designated Staff,would conduct today's visit and she arrived at 10:34am to conduct the visit. The reason for today’s visit was provided.

On 8/28/24, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above eleven allegations and also to conduct a 24 hour health and safety check. LPA Yee was let into the home by Ada Bozkrurt, Staff. Staff contacted Rebeka Durgaryan, Administrator via telephone and she arrived at 1:06pm to conduct the visit. This complaint was also referred to the

continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

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 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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Investigation Bureau for investigation consideration on 8/28/24. The reason for today's visit was provided.
On the visit conducted on 8/28/24, LPA Yee obtained information regarding Resident's date of admission,
Resident #1's length of stay at the home, services that Resident #1 was being provided during the residents stay, reason for the hospitalization and the cause of death. A copy of Resident #1's faciity files, including list of medications, MAR logs and hospice documents were requested but was not able to be provided since the copier was out of order. Per Administrator, all the requested documents will be scanned to LPA Yee by the end of today. On 8/28/24, a tour of the facility was also conducted at 2:54pm to observe the residents and to ensure that the utilities were available, review the food supply and to observe any visually obvious deficiencies. Per tour of the facility, LPA Yee observed all the residents in bed napping or watching television, sufficient perishable and non-perishable foods were observed and additional food supply is being brought in today per staff, utilities, including the air conditioner were observed to be in use. Water temperature was tested in the common and private bathroom. Water temperature tested in the common bathroom read 119.7 degrees Fahrenheit and the water temperature in the private bathroom read 119.7 degrees Fahrenheit. The swimming pool was observed to be secured by a 5 feet fence and was locked. Visually there were no immediate safety concerns observed during today's visit. Based on the 8/28/24 visit, further investigation is needed to make a finding for all of the 11 allegations currently noted as personal rights. Exit interview was conducted with Ada Bozkurt, Staff since the Administrator had to leave at 2:16pm due to child care needs.

On 7/23/25, Licensing Program Analysts (LPAs) Christine Yee and Quoc Huynh conducted a subsequent joint complaint visit to investigate the above allegations and was let into the home by Crystal McKie, Staff. Staff contacted Rebeka Durgaryan, Administrator via telephone to advise of LPAs' visit and she arrived at 9:34am to conduct the visit. The reason for today's visit was provided. On today's visit, LPA Yee conducted interviews with the Administrator at 10:14am, Resident #4 at 1:40pm and Resident #6 at 2:56pm. LPA Huynh conducted interviews with Resident #3 at 2:07pm, Resident #2 at 2:13pm and conducted file reviews at 9:56am and reviewed medications at 2:21pm in conjunction with a required annual inspection. Based on the information received from interviews conducted, files and medications reviewed, it was determined that

continued on 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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further investigation is needed to make a finding for the above 11 Personal Rights allegations. Copies of MAR Logs, Physician Report at time of Admission, Evidence of staff training by hospice agency will be sent to LPA Yee by close of business on 7/24/25. Exit interview was conducted and a copy of the report was

provided.

On 7/24/25, LPA Christine Yee and Quoc Huynh conducted another joint subsequent complaint visit to continue further investigation of the above allegations and another interview with the Administrator, was conducted at 10:34am to obtain additional information regarding the hospice services, medications and assistance with meals. Also collected on today's visit were documents requested on the 7/23/25 visit. Training logs were requested for Staff #3 and Staff #4 during the interview and will be provided by 7/25/25. On 7/23/25, LPA Huynh conducted interviews with Staff #1 at 1:50pm and Staff #2 was at 1:41pm by LPA Huynh and was not noted on the report generated for that visit. Based on 7/24/25 visit it was determined that further investigation is still needed to make a finding for the above allegation. An Exit interview was conducted with Svetlana Petrosian, Staff since the Administrator had to leave to pick up supplies.

On today's visit, LPA Yee delivered the complaint findings of the investigation for all eleven (11) allegations.. Per interviews conducted and review of all documents collected, the investigation revealed that Resident # 1 was formerly living in a nursing home in Richfield, Utah and was being moved to California to reside at this facility. Per review of documents from the nursing home, Resident #1 had multiple comorbidities such as congestive heart failure, cirrhosis of the liver, chronic kidney disease, major depressive disorder, chronic respiratory failure with hypoxia, Type 2 diabetes mellitus with diabetic chronic kidney disease, chronic pain syndrome, hypertension, was weak, use of a pacemaker, just to name a few. Resident #1 moved into this facility on 3/31/24 and hospice services with Elara Hospice, Inc were initiated on 4/12/24 based on Resident #1’s primary diagnosis of chronic congestive respiratory failure with hypoxia and secondary diagnosis of chronic combined systolic and diastolic heart failure. Many complaints were received that Elara Hospice was not providing Resident #1 with services due to lack of hospice staffing, family wanted to know if the doctor

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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and the hospice nurse was checking on the resident, due to the resident’s decline, the oxygen concentrator was not working, and the resident couldn’t breathe and mostly, the hospice agency’s failure to respond to the family’s concerns were received while Resident #1 was under Elara Hospice’s care. The complaint also alleges that the licensee of this facility, also owns Elara Hospice. The licensee denied owning the hospice company. The Statement of Information filed with Secretary of State also confirmed that the licensee is not the owner.

The family were unhappy with the services provided by Elara Hospice, so a decision was made to transfer Resident #1’s hospice services to a hospice agency used by a friend according to the Administrator. A final comprehensive assessment report was generated by Elara Hospice in preparation for the transfer of care to Liem Hospice, was conducted. Hospice services with Liem Hospice were initiated on 6/15/24. With the transfer of hospice services, complaints continued.

Per the investigation, related to Allegation #1 - Staff neglect resulted in R1's death, the investigation revealed that Resident #1, who was 82 years was admitted to the facility on 3/31/24 from a nursing home located in Utah with multiple comorbidities that were terminal and was actively declining. Comfort services were being provided at the nursing home. On 4/5/24, five days after the resident is admitted, the family texts the Administrator and told her that Resident #1 had declined drastically this week and attributes it to neglect by staff. Resident #1 was actively declining, physically and mentally and the reason why Resident #1 was placed on hospice for comfort care and safety. Resident #1 continued to decline, even with the best of care. Per interviews conducted with the Administrator and facility staff, they do not neglect any residents. The residents interviewed also confirm that the staff are great and that they are not neglected. One resident even indicated that Resident #1 was unreasonable and required a lot of attention. Per review of the Certificate of Death, the cause of death is noted as acute respiratory failure and congestive heart failure with no mention of neglect. Based on the information obtained during the investigation, there is insufficient evidence to support the allegation that staff neglect resulted in R1’s death. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

The investigation into Allegation #2 - Staff did not seek timely medical attention for a resident. Per the

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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investigation, Resident #1 was admitted to the facility on 3/31/24. Resident’s #1’s hospice care did not begin until 4/12/24. On 4/5/24, only 5 days after arriving at the facility, the family texted the Administrator to inform her that the Resident may have pneumonia and may have a bladder infection and to let the nurse know. The Administrator responded back that the nurse was going to be at the facility that day and that they would order antibiotics. During the investigation, LPA Yee was not able to determine conclusively if the onset of the pneumonia or bladder infection occurred at the facility or at the nursing home to say the facility staff neglected the Resident, which resulted in the resident to develop pneumonia or have a bladder infection in the 4 days that they lived at the facility. Resident #1 has a history of bladder infections. On 4/9/24, the resident’s family were visiting, and they observed that Resident #1 was having difficulty breathing and took the resident’s pulse. They informed the Administrator and 911 was immediately contacted. Resident #1 was hospitalized on 4/9/24 and returned to the facility on 4/12/24. Per the investigation, staff would not have immediately observed the resident having shortness of breath while the family was visiting. Resident #1 was also diagnosed with chronic respiratory failure with hypoxia. The shortness of breath may have just been triggered during the family visit. Staff are not stationed at the residents’ bedside or hover around the residents and intrude on family visits. Based on the interview conducted, there is insufficient evidence to support the allegation that staff did not seek timely medical attention for a resident. Staff called 911 as soon as they were made aware. The call for emergency services for Resident #1 was also complicated by the fact that resident had on file a do not resuscitate order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is unsubstantiated at this time.

The investigation into Allegation # 4 - Staff did not meet R1's care needs, it is alleged that the staff were not meeting Resident #1’s incontinence needs by leaving Resident #1 in their dirty pull ups, over medicating the resident, not properly feeding the resident while eating, not meeting their oxygen needs, not keeping the resident's vitals, addressing their glucose levels, high blood pressure and that unqualified staff are providing care and supervision. Per interviews conducted with staff and residents, staff state that they do not leave residents in their dirty pull ups and residents all confirm that staff change them immediately. Staff also state

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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that they do not over medicate the residents. Resident #1 brought their own medications when they first moved in. Staff dispense the medication as it was prescribed. Resident #1 is always in pain and takes many pain medications due to shortness of breath and pain. Resident #1 is always asking for more pain pills even after they take their routine pain medications. Per the Administrator, she tells the family about it. Per the Administrator, the staff are given in-service training, but her staff are not required to do medical functions as this is not a medical facility. Per Interviews conducted with the Administrator and Resident #4, both indicate that Resident #1 is able to feed themselves. Per the Administrator, staff will feed a Resident if they are not able to feed themselves. Staff do not refuse to feed a resident. Staff fed Resident #1 for maybe a couple of days because their hands were swollen, and they couldn’t hold the spoon. They fed Resident #1 for a couple of days before they were hospitalized on 7/27/24. Resident #1 was also constantly complaining that their oxygen concentrator was not working when it was working. Staff would show Resident #1 and their family that the oxygen concentrator was working. Resident #1 would constantly say that they are not getting their oxygen even when the oxygen concentrator was working. Based on the information received during the investigation, there was insufficient evidence to support the allegation that staff did not meet Resident #1’s care needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time.

The investigation into Allegation #5 - Staff is unable to communicate effectively, revealed that Staff #4 did not speak English. Per the Administrator, Staff #4 used a phone translator to communicate. Per Rebeka, Staff #4 also shared the night shift with her if they had a complicated resident who needed more care. Per Rebeka, she and Staff #4 worked together. Staff #4 would also call her if they didn’t understand something. Per Rebeka, she did not feel that the language barrier was a concern. Staff #4 no longer worked at the facility when this complaint was received and could not be interviewed for the complaint. Due to the lack of information and the unknown whereabouts of the staff, the allegation that staff is unable to communicate effectively cannot be verified. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time.

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 15 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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The investigation into Allegation #6 - Staff is not properly trained and unqualified to care for residents was also investigated and training logs for 2024 were reviewed. Training logs showed that the staff received in-service training on the following dates: 1/21-Dementia (2 hours) 1/27 -Medication (4 hours), 2/12 Dementia – Behavioral changes, 2/20 Infection Control (2 hours), 3/8 dementia (2 hours), 4/17 dementia – therapeutic, rehabilitative activities (2 hours), 5/26 – dementia (2 hours), restricted and prohibited health condition (2 hours), 6/17 – Dementia (2 hours) and hospice (1 hour), 7/3 – medication (4 hours), 8/19 resident dignity, independence, privacy choices (2 hours), 8/13 Elder Abuse (2 hours), 9/16 - Covid-19, influenza and other respiratory diseases(1 hour), 9/9 Dementia: Effects of medication (1 hour), 10/7 – Dementia: hydration needs and validation therapy, 11/12- Personal and direct care (3 hours), 12/16 – Cultural competency and sensitivity (2 hours). Per interviews with the Administrator, Staff #1 and Staff #2, they all state that they receive training as caregivers. The home is a non-medical facility and staff do not perform medical services that require a medical license. Staff are also prohibited from performing medical services in the home if they do have a medical license. Per review of training records provided, there is insufficient evidence to support the allegation that staff is not properly trained and unqualified to care for residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time.

Per the investigation into Allegation #8 that Staff did not have planned activities for the residents, the investigation revealed that the staff are offering and providing the residents with activities such as drawing, exercises, walks making postcards, dancing, singing and board games. Many board games and activity were observed under the coffee table located in the living room. Per interview with the Administrator, she stated that the residents are offered activities, but they choose not to do any activities. Resident #1 wouldn't want to get out of bed most of the time. They cannot force the residents to do activities if they don’t want to. They prefer to watch television, use their computer or cell phone or read. Resident #6 likes to be in the living room and staff will dance, sing and do light exercises with them. This was observed during our visit on 7/23/25. Based on the information received from interviews conducted, there is insufficient evidence to support the allegation that staff did not have planned activities for the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 14 of 17

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
08/27/2024 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20240827151722

FACILITY NAME:	YMZ ASSISTED LIVING		FACILITY NUMBER:	195850179
ADMINISTRATOR:	DURGARYAN, REBEKA		FACILITY TYPE:	740
ADDRESS:	6206 KLUMP AVENUE		TELEPHONE:	(818) 358-2955
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2025
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Naira Aghajanyan, Designated Staff		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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3. Staff did not assist R1 with medication as prescribed
7. Staff have inadequate record keeping for a resident
10. Staff is sleeping while providing care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Yee conducted another subsequent complaint visit to deliver the findings of the investigation for the above allegations. LPA Yee was let into the home by Crystal McKie, Staff. Rebeka Durgaryan, Administrator, was contacted by LPA at 10:05am, to advise her of today's visit and was informed that she was on a mini vacation and Naira Aghajanyan, Designated Staff, would conduct today's visit and she arrived at 10:34am to conduct the visit. The reason for today’s visit was provided.

On 8/28/24, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above eleven allegations and also to conduct a 24 hour health and safety check. LPA Yee was let into the home by Ada Bozkrurt, Staff. Staff contacted Rebeka Durgaryan, Administrator via telephone and she arrived at 1:06pm to conduct the visit. This complaint was also referred to the

continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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Investigation Bureau for investigation consideration on 8/28/24. The reason for today's visit was provided.
On the visit conducted on 8/28/24, LPA Yee obtained information regarding Resident's date of admission,
Resident #1's length of stay at the home, services that Resident #1 was being provided during the residents stay, reason for the hospitalization and the cause of death. A copy of Resident #1's faciity files, including list of medications, MAR logs and hospice documents were requested but was not able to be provided since the copier was out of order. Per Administrator, all the requested documents will be scanned to LPA Yee by the end of today. On 8/28/24, a tour of the facility was also conducted at 2:54pm to observe the residents and to ensure that the utilities were available, review the food supply and to observe any visually obvious deficiencies. Per tour of the facility, LPA Yee observed all the residents in bed napping or watching television, sufficient perishable and non-perishable foods were observed and additional food supply is being brought in today per staff, utilities, including the air conditioner were observed to be in use. Water temperature was tested in the common and private bathroom. Water temperature tested in the common bathroom read 119.7 degrees Fahrenheit and the water temperature in the private bathroom read 119.7 degrees Fahrenheit. The swimming pool was observed to be secured by a 5 feet fence and was locked. Visually there were no immediate safety concerns observed during today's visit. Based on the 8/28/24 visit, further investigation is needed to make a finding for all of the 11 allegations currently noted as personal rights. Exit interview was conducted with Ada Bozkurt, Staff since the Administrator had to leave at 2:16pm due to child care needs.

On 7/23/25, Licensing Program Analysts (LPAs) Christine Yee and Quoc Huynh conducted a subsequent joint complaint visit to investigate the above allegations and was let into the home by Crystal McKie, Staff. Staff contacted Rebeka Durgaryan, Administrator via telephone to advise of LPAs' visit and she arrived at 9:34am to conduct the visit. The reason for today's visit was provided. On today's visit, LPA Yee conducted interviews with the Administrator at 10:14am, Resident #4 at 1:40pm and Resident #6 at 2:56pm. LPA Huynh conducted interviews with Resident #3 at 2:07pm, Resident #2 at 2:13pm and conducted file reviews at 9:56am and reviewed medications at 2:21pm in conjunction with a required annual inspection. Based on the information received from interviews conducted, files and medications reviewed, it was determined that

continued on 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 11 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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further investigation is needed to make a finding for the above 11 Personal Rights allegations. Copies of MAR Logs, Physician Report at time of Admission, Evidence of staff training by hospice agency will be sent to LPA Yee by close of business on 7/24/25. Exit interview was conducted and a copy of the report was provided.

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 12 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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and the hospice nurse was checking on the resident, due to the resident’s decline, the oxygen concentrator was not working, and the resident couldn’t breathe and mostly, the hospice agency’s failure to respond to the family’s concerns were received while Resident #1 was under Elara Hospice’s care. The complaint also alleges that the licensee of this facility, also owns Elara Hospice. The licensee denied owning the hospice company. The Statement of Information filed with Secretary of State also confirmed that the licensee is not the owner.

Per investigation into allegation #3 - Staff did not assist R1 with medication as prescribed, interview with the Administrator confirms that the facility staff did not dispense Resident #1’s medications as prescribed. However, per the Administrator, during the time that Resident #1 resided at the facility, they were not keeping Medication Administration Records (MAR log) for the residents. Per the Administrator, the only medication that was prescribed every four hours for Resident #1 was Oxycodone 5mg for pain. Oxycodone was previously prescribed on a as needed basis and due to the resident declining rapidly, Liem Hospice changed the prescription to a routine medication for management of Resident #1’s pain. Oxycodone 5mg was prescribed for every 4 hours, beginning at 8am, 12pm, 4pm, 8pm, 12am and 4am. Per the Administrator, they were able to give Resident #1 the Oxycodone doses at 8am, 12pm, 4pm and 8pm but had difficulty at 12am and 4am since the resident would be in a very deep sleep and sometimes couldn’t be woken up for the 12am and 4am doses. As a result of Resident #1 not waking up, the 2 very early morning dosages were not dispensed as prescribed. The Administrator admitted that she did not request an order change for the Oxycodone or a review of the dosage frequency to accommodate Resident #1’s sleeping needs so that medications are not missed. Per the Administrator, she spoke with the hospice doctor and the resident’s family, and she was verbally instructed not to wake the resident up. Per review of hospice notes

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 10 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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and interview conducted with hospice personnel, there were no notes to confirm that the hospice doctor gave instructions not to wake up Resident #1 to dispense the early morning medications, contrary to the standing physician's order. Resident #1 was prescribed very potent opiate medications that were required to be given in a very short span of time between doses for pain and to ensure that the resident was made comfortable. Methocarbamol 500mg, a muscle relaxant was also prescribed on top of the opiate medications. The Administrator failed to request a review of the resident’s medications or request a written change order in the frequency in which the Oxycodone dosage was to be dispensed to accommodate Resident #1’s sleep needs. On 7/13/24, Morphine Sulfate 100mg/5 ml solution, every 4 hours as needed was also prescribed and kept at the facility as part of the comfort kit if needed for emergency measures. Morphine was never prescribed as a routine medication. Per the Administrator, she and her staff do not dispense the morphine. It was part of the comfort kit and the doctor had not authorized its use. Per the Administrator, only the hospice nurse was authorized to dispense the morphine when it was determined to be needed. Per review of hospice nurse’s notes, on 7/16/24, Resident #1 was administered morphine for chest pain, on 7/25/24 morphine was administered for knee and arm pain and again on 7/26/24 for pain in the bilateral lower extremities. On the 7/26/24 hospice nurse offered the family member a fentanyl patch and it was refused. Instead, the family requested Oxycodone every 4 hours and changed the PRN frequency for Morphine 20 mg from every 4 hours as needed to every 2 hours as needed. Morphine was never prescribed as a routine medication to be given every 4 hours as noted in the complaint. No PRN Authorization letters were observed on file. Per review of hospice notes and interview with hospice personnel, there is no documentation of the hospice doctor’s instructions not to wake Resident #1 for the 12am and 4am dosage. LPA also was not able to locate any text from the family not to wake up resident, contrary to the prescribed instructions. Per hospice personnel, the only note observed was that the staff were educated in continuing to dispense the Oxycodone. Based on the interview and by own admission of the Administrator, there is sufficient evidence to support the allegation the staff did not assist R1 with medications as prescribed, therefore the allegation is substantiated at this time.

Per investigation into Allegation #7 - Staff have inadequate record keeping for a resident, interview with the

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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Administrator, reveal that the facility did not keep records of Resident #1’s medications that were dispensed and missed medications. Resident #1 also had many PRN medications and there is no record that the PRN medications were dispensed or when it was dispensed, if the doctor was contacted since there is no completed PRN Authorization Letters on file from the prescribing physician that states in writing that the resident is or is not able to determine his or her need for a prescription or non-prescription medication and what instructions were given by the doctor, the dosage that was given and the results of the medications. The family were making the decisions for the PRN medications and the Administrator was going along with it. Per interview conducted with the Administrator, the hospice agency is responsible for the care of the resident. The Administrator was educated by LPA during interviews conducted, that the responsibility of all the residents that reside at the home continues to be her responsibility regardless of whether they receive hospice or home health services. The Administrator is responsible for ensuring that the residents are receiving the services noted in the care plan and aware of any changes in the resident's condition. During the investigation, It was observed that the Administrator keeps all her facility records off-site at her home and is not available for review at the time of the visit. Hospice notes were requested on 7/24/25 and again on 7/30/25 for Elara Hospice. These records had to be requested from Elara hospice and was provided on 7/31/25. The hospice agency does not maintain a file at the facility. Per investigation conducted regarding the allegation that staff have inadequate record keeping, there is sufficient evidence to support the allegation, that staff have inadequate record keeping for a resident, therefore the allegation is substantiated at this time. Failure to have completed PRN Authorization Letters were cited during the Annual Inspection conducted on 7/23/25 and will not be re-cited for this complaint.

Investigation conducted for Allegation #10 - Staff is sleeping while providing care and supervision, the complaint alleges that the only staff that works 24 hours a day, 7 days a week was going to sleep at 8pm, and not changing the residents or dispensing the routine Oxycodone every 4 hours for pain to Resident #1. As a result, Resident #1 was not getting their Oxycodone as prescribed and the resident's pain level was out of control in the morning. Per interviews conducted with the Administrator, she denied that Staff #4, who worked the night shift was sleeping on the job at night when Resident #1 lived at the home and also denies current staff are sleeping on the job. Per the Administrator, she shared the night shift with Staff #4. She works the night shift if she has a resident that is complicated and needs a lot of care. LPA Yee was not able

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 8 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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to interview Staff #4 as they no longer work at the facility. However, per interviews conducted with current staff, Staff #1, who lives at the facility and does not have set hours, states that they work alone at night and admits to sleeping on the futon through the night. Staff #1 also indicates that they are a light sleeper and will wake up if the residents require assistance. Residents interviewed either indicated that they don't know if staff is asleep or awake at night and some indicated that staff responds to their calls for assistance at night However, the facility does not have a designated staff room and sleeping in a common area designated for other use is not permitted and therefore staff working the night shift can only be awake staff. Based on the information received from interviews conducted, there is sufficient evidence to support the allegation that Staff is sleeping while providing care and supervision, therefore the allegation is substantiated at this time. This deficiency was already cited during the Annual Inspection conducted on 7/23/25 and will not be re-cited for this complaint.

In summary, the investigation into allegation #3 - Staff did not assist R1 with medication as prescribed, allegation #7 - Staff have inadequate record keeping for a resident and allegation #10 - Staff is sleeping while providing care and supervision reveal that there is sufficient information to substantiate all three allegations at this time. As previously noted under Allegation #7 - Staff have inadequate record keeping for a resident and Allegation #10 - Staff is sleeping while providing care and supervision, the citation was issued during the Annual Inspection conducted on 7/23/25 and is not being re-cited for this complaint.

Deficiencies are cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interviews were conducted, Appeals Rights discussed and a copy was given.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 9 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/06/2025 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental care: .......(2) Once ordered by the physician the medication is given according to the physician's directions. Staff failed to dispense R1's Oxycodone at 12am and 4am as prescribed. This requirement was not met as evidenced by	1 2 3 4 5 6 7	The licensee will ensure that the residents are given their medications as prescribed. Licensee will submit a written plan of action to the Department as to how they will ensure that all residents are given their medication as prescribed or what actions will be taken to ensure prescribed medications are not
	8 9 10 11 12 13 14	Staff dispensed R1's Oxycodone at 8am, 12pm,4pm, 8pm and failed to dispense R1's Oxycodone at 12am and 4am as prescribed	8 9 10 11 12 13 14	missed. Submit the plan of action to the Department by 8/6/25.
Type A 08/06/2025 Section Cited CCR 87465(c)(3)	1 2 3 4 5 6 7	Incidental Medical and Dental care: If the resident's physician has stated in writing that the resident is unable to determine his/her own need...A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the	1 2 3 4 5 6 7	The licensee will read Title 22, Section 87465 in entirety and provide a written statement that the section was read and provide a written plan of action as to how they will ensure that dispensed PRN medications are documented and available to the Department for review. by 8/6/25
	8 9 10 11 12 13 14	dosage taken, and the resident's response.This requirement was not met as evidenced by: Resident #1 was prescribed PRN Oxycodone while under the care of Elara Hospice and was dispensed by staff. However, the facility did not document the date, time, dose given and the response.	8 9 10 11 12 13 14	of the resident

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 13 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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did not occur, therefore the allegation is unsubstantiated at this time.

Per investigation into allegation #9 - Staff made unauthorized medical decisions for the residents, it is alleged that the Administrator was making unauthorized medical decision by withholding Oxycodone from Resident #1 unless the resident asked for it, when the family complained that the resident was being over medicated when they first arrived at the facility on 3/31/24. According to the details of the complaint, the Administrator felt that the resident was taking too much Oxycodone, and made her own decision to limit Oxycodone to 2 times a day. This upset the family, since Resident #1 was used to taking for Oxycodone for many years for the pain caused by heart and kidney failure and did not have any issues. Per review of Elara Hospice notes and care plan, hospice services for Resident #1 was initiated on 4/12/24. Oxycodone 10 mg tablet every 4 hours as needed was prescribed for generalized moderate to severe body pain. The Administrator was correct in not dispensing the Oxycodone until the resident asked for it since it was prescribed as a PRN medication. Per interview conducted with the Administrator, the family told her that the nursing home had over medicated Resident #1. The Administrator vehemently denies that she told the family that she was going limit the Oxycodone to 2 pills a day when the PRN prescription indicates that Oxycodone 10 mg may be dispensed every 4 hours as needed for pain. She would never do that. Based on the investigation, there is insufficient evidence to support the allegation that Staff made unauthorized medical decisions for the residents. Although the allegations 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 unsubstantiated at this time.

Per investigation into Allegation #11 - Staff mishandled a resident, it revealed that the staff do not mishandle Resident #1. Per interview with the Administrator, she vehemently denies that she or her staff mishandles any resident. Per staff, they are gentle with the residents and treat them with respect. The residents interviewed all state that the staff do not mishandle them. They all state that the staff are great. Per interview with Resident #4, they do not have any complaints about the staff. Resident #1 was unreasonable and was mentally declining. Resident #1 blew things out of proportion. Resident #1’s legs and feet swell up and they were always in pain and taking pain medication. Resident #1 would tell the family that they were being mishandled and of course they believed the resident. That’s their mother, why would Resident #1, not be

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 16 of 17

Control Number 29-AS-20240827151722

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: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
	VISIT DATE: 08/05/2025

NARRATIVE

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believed. The staff have to touch Resident #1, who was always in pain, in order to change them. Based on the information received from interviews conducted, there is insufficient evidence to support the allegation that staff mishandled a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time.

In summary, the investigation into allegation #1-Staff neglect resulted in R1's death, allegation #2 -Staff did not seek timely medical attention for a resident, allegation #4 - Staff did not meet R1's care needs, allegation #5 - Staff is unable to communicate effectively, allegation #6 - Staff is not properly trained and unqualified to care for residents, allegation #8 - Staff did not have planned activities for the residents, allegation #9 - Staff made unauthorized medical decisions for the residents and allegation #11 - Staff mishandled a resident, there was insufficient evidence to support all the above eight (8) allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore all the above eight (8) allegations are unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 17 of 17