<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604809
Report Date: 10/17/2022
Date Signed: 10/18/2022 01:41:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
PUBLIC
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:
10/17/2022
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Karine Filikyan, AdministratorTIME COMPLETED:
01:31 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
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:
1
2
3
4
5
6
7
8
9
10
11
12
13
Subsequent visit made 10/17/2022 to correct the sections cited on 809D only. Findings remain the same.
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: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
VISIT DATE: 10/17/2022
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: 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: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
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 as evidenced by:
1
2
3
4
5
6
7
Administrator locked and removed all PRN and medication at time of visit.

***No further Action required***
8
9
10
11
12
13
14
LPA observed PRN and tylenol in 3 of 4 rooms.
8
9
10
11
12
13
14
Type A
10/24/2022
Section Cited
CCR
87470(c)(1)(f)
1
2
3
4
5
6
7
87470 (c) (1) (f) 87470 - Infection Control Requirements..An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.

The requirement is not met as evidenced by:
1
2
3
4
5
6
7
The administrator will ensure the facility is following infection control plan and the administrator will retrain the staff about the infection control and send the staff training log to LPA by POC due date.
8
9
10
11
12
13
14
On 4/26/22 1 staff was observed not wearing a mask.
8
9
10
11
12
13
14
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: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2022
Section Cited
CCR
87411(d)(3)
1
2
3
4
5
6
7
87411 Personnel requirements:
(d)(3) Skill and knowledge required to provide necessary resident care and supervision.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will review Title 22 Regulations,
Section 87411 and submit a written plan
detailing on how licensee will ensure that staff are receiving the required in-service trainings according to the Regulation and send proof of training by the POC due date.
8
9
10
11
12
13
14
Based on observation and interviews conducted with staff and residents, One staff is unable to communicate with english speaking residents.
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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4