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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604809
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:29:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220607104211
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:
07/24/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Karine FilikyanTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff hit resident
Staff covered resident's face
Staff threatened resident with harm
INVESTIGATION FINDINGS:
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The purpose of this report is to provide additional infomation regarding Staff S1's date of termination.
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Karine Filikyan.
The purpose of the visit is a subsequent complaint visit and to deliver findings from the original complaint dated 06/07/2022.
The initial visit was conducted on 06/14/2022 and the following was done:
Facility tour was conducted at 10:00 AM which included 6 client bedrooms, 2 client bathrooms, living room, dining room, kitchen, front and backyard area.
Interviews were conducted at 10:15 AM to 11:00 AM with S 1 and Administrator.
A subsequent visit was conducted on 10/05/2022 and included the following:
Interviews were conducted at 10:50 AM to 11:05 AM with Administrator.
Interview was conducted telephonically with former Staff S 1 from 11:05 to 11:20 AM. The termination date from the facility for Staff S 1 was 06/01/2022.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
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 5
Control Number 28-AS-20220607104211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
VISIT DATE: 07/24/2023
NARRATIVE
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At today's visit interviews were conducted with Staff S2 and Resident's # R 2- R 4 from 930AM to 10:10 AM. Interviews with Staff S 2 and Resident's 2-4 were done telephonically with Licensing Program Analyst (LPA)
Nune Margaryan acting as translator in the Armenian language with R2-R 4 who were Armenian speaking.
Investigation included the following:
Interviews with staff, residents, family member of Resident R 1 and video of the incident inside Resident R1's room.
In regards to the allegation Staff hit resident, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints.
Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022.
Based on LPA's interviews and record review, the investigation revealed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

In regards to the allegation Staff covered resident's face, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints.
Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022.
Based on LPA's interviews and record review, the investigation revealed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

In regards to the allegation Staff threatened resident with harm, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints.
Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022.
Based on LPA's interviews and record review, the investigation revealed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220607104211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:

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Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.
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Based on video observation and interview the licensee failed to have client free from punishment, infliction of pain and humiliation by Staff S 1 calling the client an "asshole" and threatening the resident with physical restraints, and by Staff S 1 hitting R1 with a pillow and placing the pillow over R1's face which posed an Immediate Health and Safety
Risk to resident's in care.
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Administrator to review Title 22 Regulations, Section 87468.1 on Personal Rights, and conduct an in-service staff training on Personal Rights and Mandated Reporting. Submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training.
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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: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220607104211

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:
07/24/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Karine FilikyanTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility yard is unkept
Facility pool is not secured with a gate
Staff does not ensure that COVID masking protocols are followed
Staff had inappropriate interaction with a resident
Facility smells like cigarette smoke
INVESTIGATION FINDINGS:
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In regards to the facility yard unkept, on the initial visit conducted on 06/14/2022 and subsequent visits 10/05/2022 and today's visit 06/22/2023 the facility tour was conducted at 10:00 AM which included 6 client bedrooms, 2 client bathrooms, living room, dining room, kitchen, front and backyard area.
LPA observed the yard to be properly maintained and did not see any items unkept with the lawn manicured neatly and no obstructions in the yard or passageways.
Interview with staff who stated that the yard is always kept well with an employee cleaning 1x a week.
Resident's R2- R 4 all stated that the garden is kept nice and gardener comes 1x a week.
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.
In regards to the allegation Facility pool is not secured with a gate, LPA on tour did not observe there to be a pool at the facility on visits 06/14/2022 ,10/05/2022 and today's visit 06/22/2023.
Interviews with staff and residents all stated that there has never been a pool at facility.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220607104211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
VISIT DATE: 07/24/2023
NARRATIVE
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the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
In regards to the allegation Staff does not ensure that COVID masking protocols are followed, LPA on facility visits 06/14/2022,10/05/2022 and today's visit 06/22/2023 observed staff wearing masks and the facility being equipped with a 90 day supply of PPE.
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.
In regards to the allegation Staff had inappropriate interaction with a resident, interviews with staff who stated that there has not been inappropriate interactions such as massages being done by staff to residents and nothing inappropriate.
Resident's R2- R 4 stated that there has not been any massages or any inappropriate interactions with staff and resident's.
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.
In regards to the allegation Facility smells like cigarette smoke, LPA on facility visits 06/14/2022,10/05/2022 and today's visit 06/22/2023 did not smell any cigarette smoke and did not see any cigarette buds or ashtrays at the facility.
Interview with Resident's R2-R4 who all stated that no resident or staff are smoking at the facility and there has never been a smell of smoke at the facility.
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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5