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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850194
Report Date: 12/20/2024
Date Signed: 12/20/2024 04:10:57 PM

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
08/04/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20230804102833
FACILITY NAME:DEPENDABLE OVERNIGHT CARE, INC.FACILITY NUMBER:
195850194
ADMINISTRATOR:HAYRAPETYAN, ANNAFACILITY TYPE:
740
ADDRESS:7356 LEESCOTT AVE.TELEPHONE:
(818) 578-8589
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility denied medical services to client.

Staff are not properly managing resident's medication.

Resident records are not properly maintained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to further investigate the allegations listed above. During today’s visit, LPA met with caregiver and explained the reason for the visit. Staff #1 (S1) arrived shortly after.

On 08/10/2023, the initial complaint visit was conducted by LPA between approximately 09:00 a.m. - 12:45 p.m. During the visit, LPA conducted a tour of the physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 12/04/2024, LPA reviewed medical records from Pegasus Home Health Care and interviewed representative from Pegasus Home Health Care. Additionally, on 11/05/2024, LPA obtained additional records from Resident #1s (R1s) family. On 12/20/2024, Licensing Program Manager (LPM) Desaree Perera conducted interviews with facility administrator and S1 approx. between 11:45 a.m. and 11:50 a.m. During today’s visit, LPA conducted physical plant, interviewed staff and reviewed and obtained additional pertinent documentation relevant to the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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 5
Control Number 29-AS-20230804102833
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: DEPENDABLE OVERNIGHT CARE, INC.
FACILITY NUMBER: 195850194
VISIT DATE: 12/20/2024
NARRATIVE
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Continued from 9099
It was reported that "Staff prevented resident from having visitors", “Staff are not properly managing resident’s medication”, and “Resident records are not properly maintained” as it was alleged that facility staff denied a Home Health (HH) nurse access to visit Resident #1 (R1) and facility staff did not provide R1’s family with resident records. It was further reported that when R1’s family requested the medication for R1, staff stated that R1 was taken off that medication.

During the initial interviews with facility administrator and staff, all denied that R1 was ever a resident at the facility. Additionally, there was no documentation at the facility pertaining to R1. Moreover, Administrator and two staff members were shown photos of R1, but they stated they did not recognize the person in the photos. However, records obtained and reviewed during the course of the investigation reflected that Kaiser Permanente discharged R1 to Dependable Over Night Board & Care and R1 was admitted to the facility on 04/27/2023. Facility contact person was listed as S1. Moreover, HH records reviewed reflected that HH contacted facility to schedule a visit on 07/15/2023 and spoke with S1 who informed HH nurse that the “…Pt is doing fine – taking meds, diseases under control, pt can eat and walk. If they need help they will let the pt’s sister know and MD…” It was further noted that “…Another agency attempted to go see the pt in the past and facility will not allow anyone…”

Moreover, during interview conducted with S1 on 12/20/2024, S1 recalled that R1 was indeed a resident at the facility and stated that S1 was confused when initially interviewed but remembered after. S1 admitted to not contacting the LPA to provide additional information. Additionally, S1 stated they spoke with HH nurse regarding R1 and notified that they were doing well and was able to walk. Staff stated that they were unaware why HH contacted them but that she would contact R1’s family, if warranted. Moreover, S1 stated they didn’t have any records for R1 at the time of the initial interview because they didn’t recall R1 however, later located the records. During today’s visit, LPA reviewed records for residents in care and did not observe any records onsite for R1. Administrator and S1 stated they will have to review what records they have for R1 in their archive and will send to LPA once they obtain it. Moreover, S1 stated that the family of R1 was responsible for obtaining the records from Kaiser and the facility was not responsible. S1 was not able to provide any information regarding R1’s medication or provide any documentation related to the medication.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230804102833
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: DEPENDABLE OVERNIGHT CARE, INC.
FACILITY NUMBER: 195850194
VISIT DATE: 12/20/2024
NARRATIVE
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Continued from 9099-C

Based on the information gathered, the Department has sufficient evidence to determine that staff prevented R1 from having HH visit, staff did not maintain proper resident records and staff were not managing resident’s medications properly. Therefore, the above allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) S1 was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230804102833
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: DEPENDABLE OVERNIGHT CARE, INC.
FACILITY NUMBER: 195850194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
CCR
87468.1(11)
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(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidence by:
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Licensee has agreed to review section cited and provide a statement of understanding to LPA via email by COB 01/03/2025.
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Based on interviews and records reviewed the licensee did not comply with the section cited above as a home health nurse was not allowed to conduct a visit with R1, which poses a potential health and safety rise for the residents in care.
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Type B
01/03/2025
Section Cited
CCR
87465(a)(4)
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87465 (a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee has agreed to review regulation cited and provide a statement of understanding to LPA via email by COB 01/03/2025
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Based on interviews and records reviewed the licensee did not comply with the section cited above there were no centrally stored medication records to review onsite for R1, which poses a potential health and safety risk for residents in care.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230804102833
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: DEPENDABLE OVERNIGHT CARE, INC.
FACILITY NUMBER: 195850194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
CCR
87506(a)
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87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Licensee agreed to maintain full resident files in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by COB 01/03/2025
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Based on interviews and records review the licensee did not comply with the section cited above as R1 did not have any records on site to review which poses a potential health and safety risk to residents in care.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5