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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 02/24/2022
Date Signed: 02/24/2022 03:17:14 PM



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
02/16/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220216151625
FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
02/24/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yuliya Asatryan, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility failed to provide resident with privacy
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced complaint visit to the facility today. The LPA met with staff and explained the reason for the visit. There was (2) two staff and (5) five residents present. The Administrator Yuliya Asatryan arrived at the facility shortly thereafter and LPA explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 9:37 a.m. and 10:23 a.m., conducted a plant tour at 10:08 a.m. and interviewed residents at 10:10 a.m. and 10:52 a.m. In addition the LPA spoke to a family member at 2:27 p.m.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
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 5
Control Number 29-AS-20220216151625
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: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
VISIT DATE: 02/24/2022
NARRATIVE
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Regarding the allegation: Facility failed to provide resident with privacy. It was alleged that staff members have interrupted resident conversations with visitor’s and failed to provide privacy. Interviews conducted revealed that residents are allowed to have private visitation if requested. In regard to the allegation it is alleged that Resident #1 (R1) is not allowed privacy during visitation. However, R1’s visits primarily take place in common spaces. Staff interviews revealed that they ensure to give residents and their visitors space when in common areas and have advised them of their ability to visit privately in the resident’s rooms if requested. Staff have never denied R1 the ability to have visits in their private room. Residents communicated no concerns as it related to privacy, claimed that staff allow for privacy even when on the phone. A similar allegation was indicated on complaint control # 29-AS-20211103162557, in which the allegation was unsubstantiated on 2/2/2022. Per that investigation, interviews with additional responsible parties of other residents denied claims that their visits had ever been interrupted and stated that staff always respected their privacy when visiting residents in the facility. Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to provide resident with privacy. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited regarding the complaint.

Exit interview conducted. Report findings were reviewed with the administrator. The administrator authorized staff to sign the report. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/16/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220216151625

FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
02/24/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yuliya AsatryanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is not allowing visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced complaint visit to the facility today. The LPA met with staff and explained the reason for the visit. There was (2) two staff and (5) five residents present. The Administrator Yuliya Asatryan arrived at the facility shortly thereafter and LPA explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 9:37 a.m. and 10:23 a.m., conducted a plant tour at 10:08 a.m. and interviewed residents at 10:10 a.m. and 10:52 a.m. In addition the LPA spoke to a family member at 2:27 p.m.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
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 5
Control Number 29-AS-20220216151625
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: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
VISIT DATE: 02/24/2022
NARRATIVE
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Regarding the allegation: Facility is not allowing visitors. It was alleged that on approximately 2/15/2022 the facility was not allowing indoor visitation if visitors were not fully vaccinated and had proof of a negative Covid test. Interviews conducted revealed that that there had been an instance where the staff denied access to a visitor. Staff confirmed that they had been adhering to previous department Provider Information Notice (PIN) 22-04-ASC, which indicates that indoor visitation requires visitors to be fully vaccinated and provide evidence of a negative PCR test. Staff interviews revealed that they had not been updated on the most recent PIN 22-07-ASC, dated 2/7/2022 which indicates that indoor visitation requires visitors to be fully vaccinated or provide evidence of a negative PCR test. After receiving the new information staff has not denied access to visitors as long as they are meeting the new guidelines. During today’s visit it was observed that the new PIN had been posted and staff were adhering to new guidelines. Staff understood the importance of adhering and staying current with any changes in department guidelines regarding visitation protocols. Based on the information obtained, there is sufficient evidence to support the claim the facility did not allow visitation to R1’s visitor. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Report findings were reviewed with the administrator. The administrator authorized staff to sign the report. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220216151625
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: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
87468.1(a)(11)
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87468.1(a)(11) Personal Rights of Residents in All Facilities: (a) Residents in…facilities for the elderly shall have...personal rights:(11) To have their visitors...permitted to visit privately...without prior notice. This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Administrator, and staff will review PIN 22-07-ASC issued on 2/7/2022.
2. Submit a statement of understanding regarding the PIN to CCL no later than 3/4/2022.
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Based on interviews, the Licensee did not comply with the section cited above, as visitation was denied to R1’s visitor, which poses a potential personal rights risk to residents in care.
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Facility was cited for this on 09/22/2021. Civil Penalties assessed in amount of $250 for repeat violation.
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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.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5