197608349-4-5-2022-31-AS-NMAN-CDGRD5-20220414125523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608349
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:15:09 PM

Substantiated

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: 59	DATE:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Marine Karapetian - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility emergency exits are not secure

INVESTIGATION FINDINGS:

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This is an amendment of the report issued on 07/02/21 to change the findings.

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

LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents pertinent to the investigation and interviewed the administrator at 10:22 AM. On 07/02/21, LPA conducted physical plant tour at 9:25 AM and on 12/22/21 at 9:10 AM with LPM Naira Margaryan and LPA Tihesha Smith, during the physical plant tour on both occasions, LPAs and LPM observed that the exit door facing Hubbard Street was being used by the residents to smoke at the back and to get out of the facility without signing in or out at the facility.

(continued on LIC 9099-C)

Substantiated

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: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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 3

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: 04/05/2022

NARRATIVE

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(continued from LIC 9099)

The emergency exit is a one way exit, once a person gets out, that person could not come back in using the emergency exit, but the residents who smoke on the back alley block the door to fully close in order to come in using the same emergency exit. The emergency exit door has an alarm and was working but it did not deter the residents from exiting from the emergency door making it unsafe for the residents in care. Therefore, based on LPAs and LPM observation, the allegation is deemed substantiated at this time.

Citation issued. Appeal rights discussed and given.

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: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2022 Section Cited CCR 87705(k)(6)	1 2 3 4 5 6 7	Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement is not met as evidenced by, based on LPAs and LPM's observation, the licensee did not ensure that the emergency	1 2 3 4 5 6 7	Cleared during visit. During physical plant tour today, LPA observed the new emergency locking system on the emergency exit door and no one is now using it to exit.
	8 9 10 11 12 13 14	exit is secured for all the residents in care. This poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

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