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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604809
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:16:28 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2022 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20220418123049
FACILITY NAME:CHATEAU MAGNOLIAFACILITY NUMBER:
197604809
ADMINISTRATOR:KARINE FILIKYANFACILITY TYPE:
740
ADDRESS:1061 EAST MAGNOLIA ST.TELEPHONE:
(818) 843-5873
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY:6CENSUS: 4DATE:
04/26/2022
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Karine Filikyan, Administrator TIME COMPLETED:
02:31 PM
ALLEGATION(S):
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Staff are unable to communicate due to language barrier
Medications were left accessible to residents
Staff do not follow protocals to prevent the spread of COVID-19
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to the facility. LPA was greeted by caregiver who was not wearing a mask and did not screen LPA as required. Administrator arrived a little later. Facility tour was conducted at 9:47am which included 6 client bedrooms, 2 client bathrooms, living room, dining room and kitchen. Interviews were conducted with Administrator, House manager and staff #1 and #2. Interviews were conducted with R1 and R2

Regarding allegation: Staff do not follow protocols to prevent the spread of COVID-19

LPA was greeted by S1 and S1 was not wearing a mask and did not screen LPA at entrance. A tray was set up at entrance to screen, but screening was not done. LPA observed Administrator and house manager wearing mask most of the time of visit, Administrator would pull mask down under her chin and house manager wore mask under her nose.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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 4
Control Number 28-AS-20220418123049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
VISIT DATE: 04/26/2022
NARRATIVE
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Regarding the allegation: Staff are unable to communicate due to language barrier with residents, on visit conducted 04/26/22 and based on LPA's observation and interviews staff member who greeted LPA had difficulty communicating because of the language barrier. S1 stated did not understand English very well. R1 stated that the language barrier is the barrier that most affects care and needs.

Regarding allegation: Medications were left accessible to residents, LPA, administrator and S1 observed medication and PRN (vitamins) accessible to clients. LPA observed the cabinet with key hanging from the lock and drawer of medications under kitchen cabinet unlocked.

During visit LPA observed S2 working and not being associated with facility. S2 stated today was her first day. S2 was sent home during visit.

Civil penalties issues.

Based on LPA's observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20220418123049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/03/2022
Section Cited
HSC
1569.50(a)(3)
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The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
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Licensee shall ensure that facility is following California Dept of Public Health and CCLD requirements. Provide a written statement stating that facility staff were re-trained and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.
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This requirement was not met by evidence of
On January 26, 2022 2 staff were observed not wearing face coverings.
On 4/2622 1 staff was observed not wearing a mask.

This poses an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type B
05/03/2022
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of:
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Facility to submit a plan by POC due date addressing staff's competency to provide services necessary to meet resident's needs in the future.
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Based on observation licensee failed to have personnel competent to provide services necessary with LPA observing staff member unable to answer questions and stated she did not understand English very well. This poses an immediate health and safety risk to residents in care. Prior violation within 12 months.
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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: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220418123049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2022
Section Cited
CCR
97465(h)(2)
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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement was not met by evidence of:
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Administrator locked and removed all PRN and medication at time of visit.
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LPA observed PRN and tylenol in 3 of 4 rooms.
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Type A
04/26/2022
Section Cited
HSC
87219(e)
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Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption

This requirement was not met as evidenced by

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Administrator will associated S2 prior to working at facility. S2 was sent home during visit. Civil penanty assesesd $100
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LPA Observed S2 working at facilty and not associated to facility.
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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: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4