197608349-8-26-2022-31-AS-RRAZ-CK9SPN-20221016140322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608349
Report Date: 08/26/2022
Date Signed: 08/26/2022 04:33:04 PM

Unsubstantiated

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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210204161317

FACILITY NAME:	ABBEY ROAD VILLA		FACILITY NUMBER:	197608349
ADMINISTRATOR:	MARINE KARAPETIAN		FACILITY TYPE:	740
ADDRESS:	14132 HUBBARD STREET		TELEPHONE:	(818) 837-0077
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	78	CENSUS: 53	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	03:04 PM
MET WITH:	Marine Karapetian - Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple fractures while in care

Facility staff did not have resident reappraised

Resident sustained multiple falls while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegations. LPA met with Administrator Marine Karapetian and explained the reason for the visit.

On 02/042021, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Brian Slatic.

On 02/05/2021 at 1:02 PM, LPA Tan initiated the complaint visit. LPA Tan interviewed the administrator and obtained copies of the facility records relevant to the investigation.

During the course of the investigation, LPA Tan interviewed the administrator on 02/05/2021 at 1:50 PM. Investigator Slatic interviewed the administrator and assistant administrator on 05/21/21.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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 3

Control Number 31-AS-20210204161317

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ABBEY ROAD VILLA	FACILITY NUMBER: 197608349
	VISIT DATE: 08/26/2022

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

(continued from LIC 9099)

Investigator Brian Slatic also attempted to interview Resident #1 (R1)’s family member multiple times from 03/11/21 to 05/03/21, left multiple messages and sent regular mail. Investigator Slatic calls were never returned, and mail was returned too.

Regarding the allegation that the Resident sustained multiple fractures while in care, it was alleged that Resident #1 fell resulting to a fractured hip. Investigator Slatic’s record review on 05/25/21 and LPA’s record review on 06/21/21 at 9:00 AM from prior placement at two Skilled Nursing Facility (SNF) revealed that there was no indication that R1 was a fall risk. Physician’s assessment prior to admission did not indicate that R1 was a fall risk. Investigator Slatic’s interview with R1’s Primary Care Physician (PCP) on 05/21/21 at 12:40 PM, revealed that the PCP had been monitoring R1’s progress since admission on 06/10/20. The PCP had a tele medicine visit on 06/10/2020 and 08/28/2020 at which time, the physician stated that R1 is appropriate for the facility up to the time of R1’s fall. LPA’s hospital medical record review also revealed that on 09/30/21 R1 was diagnosed with “acute fracture or malalignment of cervical spine”. LPA’s interview with care staff on 12/22/21, between 10:00 AM to 12:00 PM, revealed that care staff found R1 on the floor at around 7:15 AM on 09/30/21 and medication technician did the pain assessment and called the ambulance immediately, R1 was transported to the hospital at around 7:30 AM on the same day. While R1 sustained fracture during a fall in the facility, the facility staff acted accordingly to have R1 assessed and brought to the hospital immediately.

Regarding the allegation the facility staff did not have resident reappraised, it was alleged that the facility did not have a Pre-Admission Appraisal for R1’s readmission on 8/24/20. Investigator Slatic and LPA Tan’s record review revealed that R1 had a Pre-Placement Appraisal Information, Functional Capability Assessment and Resident Appraisal, all signed by a family member on 06/09/20. R1 also has an Appraisal Needs and Services (ANS) prepared on 06/10/20 for R1 but R1’s family member refused to sign and another ANS was prepared on 08/28/2020 upon R1’s return from Covid 19 quarantine from a SNF, which R1’s family member also refused to sign.

(continued on LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20210204161317

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ABBEY ROAD VILLA	FACILITY NUMBER: 197608349
	VISIT DATE: 08/26/2022

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

(continued from LIC 9099-C)

Regarding the allegation that resident sustained multiple falls while in care, it was alleged that R1 had multiple falls while in the facility. Investigator Slatic and LPA’s record review revealed that during the stay of R1 from admission on 06/09/20 and hospitalization on 09/30/20, R1 only fell once. Resident had an unwitnessed fall. R1 was found sitting on the floor of own room by the staff to get R1 ready for breakfast at 7:10 AM on 09/30/20. Further record review also revealed that the facility had an established fall prevention and post fall protocol which was utilized on R1’s fall. R1 did not return to facility after this fall.

Based on information gathered during the course of the investigation, the allegations are deemed unsubstantiated at this time

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3