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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608349
Report Date: 04/16/2024
Date Signed: 05/10/2024 12:15:31 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
04/10/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240410154132
FACILITY NAME:ABBEY ROAD VILLAFACILITY NUMBER:
197608349
ADMINISTRATOR:MARINE KARAPETIANFACILITY TYPE:
740
ADDRESS:14132 HUBBARD STREETTELEPHONE:
(818) 837-0077
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:78CENSUS: 66DATE:
04/16/2024
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Marine Karapetyan - AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not provide resident’s records to resident’s authorized representative in a timely manner
INVESTIGATION FINDINGS:
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This report is amended to change the findings.
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this to investigate the above allegation. LPA met with administrator Marine Karapetyan and state the reason for the visit.

LPA conducted physical plant tour at 9:30 AM, requested copies of facility documents relevant to the investigation at 9:49 AM and interviewed the administrator at 10:49 AM. It was alleged that the staff did not provide Resident #1 (R1)’s records to R1’s authorized representative who allegedly faxed the request to the facility on 03/12/24 but was not able to obtain the document until 04/12/24. LPA's interview with the administrator today at 10:49 AM revealed that the R1's authorized representative sent personnel to obtain copies of R1's records on 04/12/24, the administrator however denied that she received the faxed written request on 03/12/24 and only learned about it when R1's authorized representative called which she welcomed coming to the facility to obtain copies of R1's record. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted and copy of this report issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
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 2
Control Number 31-AS-20240410154132
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2024
Section Cited
CCR
87468.2(a)(19)
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(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.
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Cleared during visit. The facility had already provided the requested documents on 04/12/24
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This requirement is not met as evidenced by:

Based on record review and interview the licensee did not provide the records of R1 to the R1's authorized representative in a timely manner which poses a potential personal rights risk to the residents in care.
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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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC9099 (FAS) - (06/04)
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