197608349-6-15-2023-31-AS-TAGD-D3LUDT-20240322153005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608349
Report Date: 06/15/2023
Date Signed: 06/15/2023 01:33:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
06/13/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230613135958

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: 66	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Marine Karapetyan - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff do not ensure residents use designated smoking area to smoke

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with the administrator Marine Karapetyan and explained the reason for the visit.

LPA conducted physical plan tour at 9:15 AM, requested copies of facility documents relevant to the investigation at 9:40 AM and interviewed staff and residents between 9:45 AM to 11:30 AM. It was alleged that the Administrator lets the residents smoke by the front door which is always open and the smoke comes inside the facility. LPA observation today during physical plant tour at 9:15 AM revealed that the smoking area is less than 15 feet (14'10" to be exact) away from the front or main door of the facility and also has a sign that says "No Smoking" and "Please always keep the doors closed". LPA's interview with the administrator at 9:45 AM revealed that the administrator does not allow anyone to smoke by the front door but there are residents who do despite numerous warnings. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230613135958

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ABBEY ROAD VILLA	FACILITY NUMBER: 197608349
	VISIT DATE: 06/15/2023

NARRATIVE

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(continued from LIC 9099)

LPA's interview with three (3) staff today between 9:45 AM to 11:30 AM revealed that all three (3) of them saw residents smoking by the front door but whenever they see them smoking, they told them to go to the smoking area and/or bring them there if the resident is on wheelchair. Further, all three (3) staff stated that they also closed the door every time they see it open. LPA's interview with three (3) smoking residents today between 9:45 AM to 11:30 also revealed that all three (3) residents stated that they are always reminded by the staff or by the administrator not to smoke near the front door.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

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