197608349-5-28-2024-31-AS-MVAO-D5VT27-20240603142016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608349
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:39:43 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
08/15/2022 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220815142833

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: 69	DATE:	05/28/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Marine Karapetian		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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1. Resident was not given medication as needed
2. Resident was not provided eyeglasses as needed
3. Resident was not provided a wheelchair as needed
4. Resident was not provided oxygen as needed
5. Resident(s) not accorded dignity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with administrator Marine Karapetyan and explained the reason for the visit. The following was determined:

Allegation # 1: It was alleged that resident was not given medication as needed. On 08/22/2022, former LPA Wendell Smith conducted the initial complaint visit and obtained documents pertaining to the investigation. During today’s visit, from 915am to 230pm, LPA conducted a physical plant inspection, additional interviews and obtained and reviewed documents. It was reported staff did not administer medication to resident # 1(R1). LPA attempted to interview (R1), and witnesses involved in the complaint; but was not successful. LPA reviewed documents, and it revealed that (R1) was administered medication according to the date that is in question. Residents interviewed today, reported to LPA, staff administer medication as directed. Therefore, based on documentation review, and interviews, the allegation is Unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

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-20220815142833

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: 05/28/2024

NARRATIVE

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Allegation # 2: It was alleged that resident was not provided eyeglasses as needed. On 08/22/2022, former LPA Wendell Smith conducted the initial complaint visit and obtained documents pertaining to the investigation. During today’s visit, from 915am to 230pm, LPA conducted a physical plant inspection, additional interviews, and attempted to interview (R1) and witnesses involved in the complaint; but was not successful. Interviews revealed (R1) was hospitalized for a short period of time, and during that time, the facility started to repair the plumbing issues in (R1’s) room. (R1) was discharged before the repairs were completed. (R1) had to be relocated to a temporary room and (R1’s) important personal belongings were transferred to the temporary room by staff, and the Administrator. (R1) was also allowed to enter (R1’s) room at any time, during the repair to gather any personal belongings (R1) wanted. (R1) also did not inform staff about the eyeglasses. Therefore, based on interviews, the allegation is Unsubstantiated at this time.
Allegation # 3: It was alleged resident was not provided a wheelchair as needed. On 08/22/2022, former LPA Wendell Smith conducted the initial complaint visit and obtained documents pertaining to the investigation. During today’s visit, from 915am to 230pm, LPA conducted a physical plant inspection, additional interviews, and attempted to interview (R1) and witnesses involved in the complaint; but was not successful. Interviews revealed (R1) was hospitalized for a short period of time, and during that time, the facility started to repair the plumbing issues in (R1’s) room. (R1) was discharged before the repairs were completed. (R1) had to be relocated to a temporary room and (R1’s) important personal belongings were transferred to the temporary room by staff and the Administrator. LPA was informed, that (R1) mainly used (R1’s) walker and did not use the wheelchair. (R1) was also allowed to enter (R1’s) room during the repair to gather any personal belongings (R1) wanted. (R1) did not mention to staff, that (R1) needed the wheelchair. Therefore, based on interviews, the allegation is Unsubstantiated at this time.
Allegation # 4: It was alleged resident was not provided oxygen as needed. On 08/22/2022, former LPA Wendell Smith conducted the initial complaint visit and obtained documents pertaining to the investigation. During today’s visit, from 915am to 230pm, LPA conducted a physical plant inspection, additional interviews, and attempted to interview (R1). LPA also attempted to interview witnesses involved in the complaint; but was not successful. Interviews revealed (R1) was hospitalized for a short period of time, and during that time, the facility started to repair the plumbing issues in (R1’s) room. (R1) was discharged before the repairs were completed. (R1) had to be relocated to a temporary room and (R1’s) important personal belongings were transferred to the new room by staff and the Administrator, including (R1’s) oxygen. (R1) also always carries a small and portable oxygen tank. Therefore, based on interviews, the allegation is Unsubstantiated at this time.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20220815142833

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: 05/28/2024

NARRATIVE

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Allegation # 5: It was alleged resident(s) not accorded dignity. On 08/22/2022, former LPA Wendell Smith conducted the initial complaint visit and obtained documents pertaining to the investigation. During today’s visit, from 915am to 230pm, LPA conducted a physical plant inspection, additional interviews, and attempted to interview (R1) and witnesses involved in the complaint; but was not successful. LPA interviewed residents today, and they reported, staff do treat them with respect and dignity. Therefore, based on interviews, the allegation is Unsubstantiated.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC9099 (FAS) - (06/04)

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