197608349-12-22-2021-31-AS-NMAN-CDGRD6-20220414125523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608349
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:24:33 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
06/28/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210628093855

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: 54	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Marine Karapetian - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not adhere to Public Health directive to wear mask

INVESTIGATION FINDINGS:

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This is an amendment of the report issued on 09/16/21 to change the findings.

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

LPA conducted physical plant tour at 9:10 AM. At 9:45 AM, LPA requested and reviewed facility documents relevant to the investigation. Between 10:15 AM to 12:45 PM, LPA interviewed staff and residents of the facility.

During LPA's physical plant tour during today's visit at 10:00 AM, on 09/16/21 at 9:10 AM and on 07/02/21 at 9:25 AM, LPAs observed that all staff are wearing mask all while working at the facility.

(continued on LIC 9099)

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: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20210628093855

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: 12/22/2021

NARRATIVE

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(continued from LIC 9099)

LPAs' Smith and Tan interviewed six (6) residents today between 1:00 PM to 2:15 PM. LPAs' interview revealed that six (6) out of six (6) residents observed that the staff always wear mask while working at the facility.

Based on the information gathered during this and prior visits, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this 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: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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