195850239-5-12-2023-29-AS-JAPL-CRVPG6-20230516111749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850239
Report Date: 05/12/2023
Date Signed: 05/12/2023 02:43:02 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
05/09/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230509142243

FACILITY NAME:	SILVER LIGHT CARE		FACILITY NUMBER:	195850239
ADMINISTRATOR:	KHACHATRYAN, ELBA		FACILITY TYPE:	740
ADDRESS:	8201 VANTAGE AVENUE		TELEPHONE:	(747) 228-4111
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 3	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Elba Khachatryan		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff admitted resident without completing an individual written admission agreement with resident or the resident's representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Sandra Urena conducted an initial visit to investigate the allegation listed above. The LPA arrived at the facility at 10:05 a.m. was greeted by staff and explained the reason for the visit. Administrator Elba Khachatryan arrived at 10:59 a.m., and LPA explained the reason for the visit.

LPA Urena interviewed staff (S1) from 10:35 a.m. to 10:44 a.m., and the administrator from 10:59 a.m. to 11:42 a.m. Reviewed records at 10:45 a.m. The LPA interviewed the complainant on 04/11/2023 from 10:12 a.m. to 11:05 a.m.

Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20230509142243

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: SILVER LIGHT CARE	FACILITY NUMBER: 195850239
	VISIT DATE: 05/12/2023

NARRATIVE

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Per the allegation, ‘Staff admitted resident without completing an individual written admission agreement with resident or the resident's representative’, it is the complainant’s concern that the facility never informed R1’s responsible parties of the restrictions for caring for R1, and R1 was thrown out within one day of being admitted. To investigate the allegation, the LPA interviewed the complainant. Per the complainant’s statement, the responsible parties for R1 contacted the facility staff to have R1 admitted to facility for a short period of time (approximately six days). The Administrator stated to the responsible parties that they would stop by the house of the responsible parties to drop off an admission agreement, prior to R1 being admitted to the facility; however, facility staff never showed up prior to 3/8/2023. On 3/8/2023, R1 was picked up from the responsible parties’ home by a van service and took R1 to the facility and drop them off at approximately at 12:00 p.m. On the evening of 3/08/2023 the facility staff contacted the responsible parties to have R1 picked up from the facility because R1 could not be cared at the facility. Per the complainant, the responsible parties were on a plane and could not continue communicating with the facility staff due to connectivity issues. The facility staff then contacted the additional responsible parties on 03/09/2023 at approximately 12:00 AM to have R1 picked up from the facility, because R1 was being loud, and staff could not take care of them. Complainant stated that the responsible parties for R1 had made a payment by check to the facility staff for $1,200 dollars for R1’s care and supervision at the facility for a period of six days at $200 dollars per day. The facility staff charged them $200 dollars for one day and refunded the responsible parties $1000 dollars with a personal check. Additionally, the complainant stated that the facility staff contacted the responsible parties’ days (did not say how many days), after R1 had been picked up from the facility to ask them to complete the Admission Agreement. The complainant stated that the responsible parties never filled out the paperwork and only communicated with the facility staff via text. The LPA interviewed the administrator, and the interview revealed that they admitted R1 in the facility for one day. The Administrator stated that they did not have a for for the R1, therefore an Admission Agreement was not created for R1.

Based on the information obtained through interviews and record review, there is sufficient evidence to support the allegation that facility staff admitted the resident without completing an admission agreement with resident or the resident's representative. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (please refer to LIC 9099-D).

Exit interview conducted with the administrator, A copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230509142243

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: SILVER LIGHT CARE	FACILITY NUMBER: 195850239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2023 Section Cited CCR 87507	1 2 3 4 5 6 7	87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement,...(g) Admission agreements shall specify the following:(A) Rate for all basic services which the facility is required to provide in This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will review the regulation about Admission Agreements and will send by 05/19/2023 a written statement that they will comply with the regulation for future residents.
	8 9 10 11 12 13 14	Based on record review, the licensee failed to comply with the section cited above as R1’s file was not completed and did not have a signed admission agreement, which poses a potential personal rights 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: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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