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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608116
Report Date: 03/15/2022
Date Signed: 03/16/2022 08:31:41 AM



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
03/08/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220308114953
FACILITY NAME:ELDERCARE VILLAFACILITY NUMBER:
197608116
ADMINISTRATOR:MIKHAIL MINKOVFACILITY TYPE:
740
ADDRESS:7754 COLDWATER CANYON AVENUETELEPHONE:
(818) 764-2526
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 6DATE:
03/15/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tina ArutyunyanTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff twisted the resident's hand.
Staff pins the resident down.
Staff covers the resident face with a pillow.
Staff forces resident to take medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility to conduct an initial 10-day visit. The LPA met with staff Tina Arutyunyan, and explained the reason for the visit.

The LPA and the administrator conducted a tour of the facility at 10:00 a.m. LPA Urena conducted residents’ interviews, from 10:30 a.m. to 11:00 a.m., staff interviews from 11:00 a.m. to 12:30 p.m., resident’s responsible parties from 2:00 p.m. to 2:30 p.m., and hospice services from 3:15 p.m. to 3:45 p.m. LPA requested pertinent records for the allegations.

At 10:30 a.m., the LPA interviewed two residents out of the five residents. The two residents interviewed revealed that they were happy with the services provided at the facility; and, that they were very well treated by staff. One out of the three residents were unavailable, one of the two residents were unable to answer the LPA’s questions.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
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-20220308114953
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: ELDERCARE VILLA
FACILITY NUMBER: 197608116
VISIT DATE: 03/15/2022
NARRATIVE
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At 3:15pm, LPA Urena contacted hospice services for Resident #1 (R1) to inquire about the notes for the continuous care provided to R1. The LPA spoke with the Registered Nurse Team Leader, who stated that the record review of the visits do not show any incidents or bruising to the R1’s face or hands.

Regarding the allegation that staff twisted the resident's hand, it is alleged that R1’s hand was twisted by staff. To investigate this allegation, LPA Urena interviewed residents, staff, and responsible parties. LPA Urena attempted to interview R1, but R1 was unable to respond to questions asked by the LPA. R1 appeared to be in a state of confusion and could not answer basic personal questions, e.g. name, date of birth, month or the year, etc.

LPA Urena interviewed Staff #1(S1) at 11:00 a.m. LPA Urena asked S1 about incidents with residents. S1 stated that on one occasion, R1 had become agitated and aggressive towards S1 during a routine check to assist R1 with repositioning and medication. S1 stated that R1 pulled S1’s hair and pushed S1 with their legs. The LPA asked S1 if S1 had twisted R1’s hand? S1 stated that S1 did not. S1 stated that S1 held R1’s hand and tried to pry open the R1’s hand/fingers to let go of S1’s hair. S1 further stated that that incident happened only once, the day after R1 was admitted to the facility. After that day, R1’s hospice care placed a nurse on the premises for continuous 24-hour care to stabilize R1’s medication.

LPA Urena interviewed Staff #2(S2) about the allegation. The S2 stated that they were aware of the incident that took place the day after R1 was admitted to the facility. S2 stated that S2 received the call from S1 about the incident, and about R1’s aggressive and agitated behavior. S2 had instructed S1 to call 9-1-1 if R1 did not calm down. S2 then called R1’s responsible parties who showed up at the facility a couple hours after S2 called them to inform them of the incident. S2 did not observe any inappropriate behavior between S1 and any facility residents.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220308114953
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: ELDERCARE VILLA
FACILITY NUMBER: 197608116
VISIT DATE: 03/15/2022
NARRATIVE
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LPA Urena reached R1’s responsible party (RP) via a telephone call and asked if the RP was aware of the incident that took place the day after R1 arrived at the facility? The RP stated that they were informed by S2 and the RP were summoned to the facility to discuss R1 actions and needs after this incident. The RP stated that R1 suffers from psychosis and has a habit of making accusations, “that’s what [R1] does, [R1] accuses people when things don’t go their way”. “[R1] did the same at the last two medical facilities, [R1] has accused people of abuse.” LPA Urena asked the RP if they saw R1 during their visit at the facility and if they saw any bruising? The RP replied that they didn’t want to be seen by R1. The RP stated that R1’s responsible parties do not want to be alone with R1 because R1 makes false accusations and the RPs are afraid to be put in that situation of having to defend themselves.

The LPA reviewed R1’s medical records dated 2022. The medical records notate that R1 has admitted that since being diagnosed with a particular disease, and placed on the medication for the disease, R1 has been experiencing auditory and visual hallucinations. Further review of R1’s medical records indicate a medical diagnosis of anxiety, hallucinations, and paranoid psychosis. Based on the interviews and record review, there is insufficient evidence to support the claim that staff twisted R1’s hand. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation that ‘Staff pins the resident down’, it is alleged that staff pinned R1 down. To investigate this allegation, LPA Urena interviewed Staff #1(S1) at 11:00 a.m. LPA Urena asked S1 about incidents with residents. The S1 stated that on one occasion R1 had become agitated and aggressive towards S1 during a routine check to assist R1 with repositioning and medication. S1 stated that R1 pushed S1 with their legs. The LPA asked S1 if S1 had pinned R1 down? S1 stated that S1 did not. S1 stated that R1 is not able to get out of bed and S1 simply moved away from R1. S1 further stated that that incident happened once, the day after R1 was admitted to the facility. After that day, R1’s hospice services placed a nurse for continuous 24-hour care to stabilize R1’s medication.

LPA Urena interviewed Staff #2(S2) about the allegation. S2 stated that they were aware of the incident that took place the day after R1 was admitted to the facility. S2 stated that S2 received the call from S1 about the incident, and about R1’s aggressive and agitated behavior. S2 instructed S1 to call 9-1-1 if R1 did not calm down. S2 then called R1’s responsible parties (RP) who showed up at the facility a couple hours after the S2 called them to inform them of the incident. LPA Urena attempted to interview R1, but R1 was unable to respond to questions asked by the LPA. R1 appeared to be in a state of confusion and could not answer basic personal questions, e.g. name, date of birth, month or the year, etc.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220308114953
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: ELDERCARE VILLA
FACILITY NUMBER: 197608116
VISIT DATE: 03/15/2022
NARRATIVE
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LPA Urena reached out to the RP via telephone call, and asked if RP was aware of the incident that took place the day after R1 arrived at the facility? RP stated that they were informed by S2. The RP stated that R1 suffers from psychosis and has a habit of making accusations “that’s what [R1] does, [R1] accuses people when things don’t go their way”. “[R1] did the same at the last two medical facilities, [R1] has accused people of abuse.” Based on the interviews and record review, there is insufficient evidence to support the claim that staff pins the resident down. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation that ‘Staff covers the resident face with a pillow’, it is alleged that R1’s face was covered with a pillow by staff. To investigate this allegation, LPA Urena interviewed Staff #1(S1) at 11:00 a.m. LPA Urena asked S1 about incidents with residents and if at any time S1 had covered R1’s face with a pillow? The S1 stated that S1 did not. The S1 mentioned the aggressive behavior displayed by R1 and R1 grabbing S1’s hair and pushing S1 with their feet. LPA Urena attempted to interview R1, but R1 was unable to respond to questions asked by the LPA. R1 appeared to be in a state of confusion and could not answer basic personal questions, e.g. name, date of birth, month or the year, etc.

Responsible parties (RP) for R1 were informed of this incident by S2. There comment was “that’s what [R1] does, [R1] accuses people when things don’t go their way. [R1] did the same at the last two medical facilities, [R1] has accused people of abuse.” Therefore, based on the interviews and record review, there is insufficient evidence to support the claim that staff covers the resident face with a pillow. This allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220308114953
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: ELDERCARE VILLA
FACILITY NUMBER: 197608116
VISIT DATE: 03/15/2022
NARRATIVE
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Regarding the allegation that ‘Staff forces resident to take medications’, it is alleged that staff will force R1 to take their medications. To investigate this allegation, LPA Urena interviewed Staff #1(S1) at 11:00 a.m. LPA Urena asked S1 about incidents with residents and if at any time S1 forced R1 to take medications? S1 stated that R1 has not refused to take the medications. S1 added that if residents refuse to take their medications, it is reported to their doctor; refusing medication would be violating the facility rules. A medication record review of the Centrally Stored Medication Administration Record (MARS), indicated that the medications are being provided per doctor’s instructions. LPA Urena attempted to interview R1, but R1 was unable to respond to questions asked by the LPA. R1 appeared to be in a state of confusion and could not answer basic personal questions, e.g. name, date of birth, month or the year, etc.

Based on the interviews and record review, there is insufficient evidence to support the claim that staff forces resident to take medications. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5