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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608349
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:58:57 PM



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
11/30/2021 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20211130101037
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: 51DATE:
12/06/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marine Karapetian & Virginia SumulongTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident attacked another resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit, and met with Administrator Marine Karapetian and Co-Administrator Virginia Sumulong, to discuss and obtain information pertaining to the allegation mentioned above. The following was determined:

On 11/30/2021 and 12/01/2021, LPA attempted to contact the complainant to obtain information regarding the complaint. It was alleged that a resident attacked another resident while in care. On 12/06/2021, from 11am to 130pm, LPA reviewed facility documents, and conducted interviews with the Administrators, resident # 1(R1) and resident # 2 (R2). It was reported to LPA, that there has been previous issues between R1 and R2, with verbal insults; but never physical altercations. R1 reported to LPA that on 11/28/2021, R2 had been agitated and using profanity the whole day. R1 was walking to R1's bedroom, when R2 got up from the
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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-20211130101037
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: 12/06/2021
NARRATIVE
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couch, and attempted to chase R1. R1 fell to the ground, and sustained an injury to the head. R1 was taken to the hospital. R1 also reported to LPA, that R1 was not attacked by R2. R2 did not want to be interviewed by LPA. Therefore, the allegation, "Resident attacked another resident while in care", is UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2