197604809-4-14-2022-28-AS-WSHO-CDLR3Y-20220418124040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604809
Report Date: 03/02/2022
Date Signed: 04/14/2022 12:48:08 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
01/18/2022 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220118125103

FACILITY NAME:	CHATEAU MAGNOLIA		FACILITY NUMBER:	197604809
ADMINISTRATOR:	KARINE FILIKYAN		FACILITY TYPE:	740
ADDRESS:	1061 EAST MAGNOLIA ST.		TELEPHONE:	(818) 843-5873
CITY:	BURBANK	STATE: CA	ZIP CODE:	91501
CAPACITY:	6	CENSUS: 4	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Staff 1		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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9

Staff are unable to communicate with residents due to language barrier.
Staff not wearing masks.

INVESTIGATION FINDINGS:

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This report is amended to remove staff names. Previously issued LIC 9099s are rescinded. The amendment does not change the findings. LPA Nune Margaryan redelivered report on 04/14/2022 to obtain signatures.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff 1. Initial visit was conducted on 1/26/22 and the following was done: Facility tour was conducted at 10:AM which included 6 client bedrooms, 2 client bathrooms, living room, dining room and kitchen. Interviews were conducted at 10:15 AM with Client 1 and 11:30 AM with Client 2. Interviews were conducted from 10:30 AM to 11:30 AM with Staff 1 -3.
In regards to the allegation Staff are unable to communicate with residents due to language barrier, on initial visit conducted 1/26/22 based on LPA's observation staff member who greeted LPA had difficulty communicating because of the language barrier. LPA asked questions of where could the computer be set up and is the administrator present. Staff member did not understand questioning and requested to use a mechanical translator to help translate what was communicated. The staff member was the only staff on duty at that time. Staff member also asked for a resident's assistance to help in understanding LPA's questions.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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-20220118125103

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: 03/02/2022

NARRATIVE

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

In regards to the allegation Staff not wearing masks, based on LPA's observation on initial visit conducted 1/26/22 the staff member who greeted LPA at the door did not have a mask on and was providing care to residents at that time.
Shortly thereafter Staff 2 arrived to greet the LPA and was not wearing a mask.
At today's visit 03/02/22 Staff 1 who greeted LPA was observed without a mask on and was providing care to residents at that time.

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/18/2022 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220118125103

FACILITY NAME:	CHATEAU MAGNOLIA		FACILITY NUMBER:	197604809
ADMINISTRATOR:	KARINE FILIKYAN		FACILITY TYPE:	740
ADDRESS:	1061 EAST MAGNOLIA ST.		TELEPHONE:	(818) 843-5873
CITY:	BURBANK	STATE: CA	ZIP CODE:	91501
CAPACITY:	6	CENSUS: 4	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Staff Siranush Tarkhanyn.		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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9

Facility is not clean.

INVESTIGATION FINDINGS:

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In regards to the allegation Facility is not clean, LPA toured the facility on the initial visit conducted 1/26/22 which included 6 client bedrooms, 2 client bathrooms, living room, dining room and kitchen.
LPA observed all client bedrooms to be clean. All the bathrooms were clean. Dining room area and kitchen were also observed to be in good order and were clean. Living room area was clean and drawers with utensils were kept neat and clean in the kitchen area.
LPA did not observe any areas of the facility that were unkept.

Although the allegation 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.
Exit interview conducted and copy to be provided via e-mail.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220118125103

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: 03/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/03/2022 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	This requirement was not met by evidence of: On January 26, 2022 2 staff were observed not wearing face coverings. On 3/2/22 1 staff was observed not wearing a mask. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/09/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	This requirement was not met by evidence of: Based on observation licensee failed to have personnel competent to provide services necessary with LPA observing staff member unable to answer questions without use of a mechanical translator This poses an immediate health and safety risk to residents in care.	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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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