197608534-6-8-2022-29-AS-JAPL-CFLS54-20220621133345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608534
Report Date: 06/08/2022
Date Signed: 06/08/2022 09:34:26 AM

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220606163942

FACILITY NAME:	ASSISTED COMFORT HOME		FACILITY NUMBER:	197608534
ADMINISTRATOR:	MARIAM KEVLIYAN		FACILITY TYPE:	740
ADDRESS:	23731 KILLION STREET		TELEPHONE:	(818) 800-9970
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	06/08/2022
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Mariam Kevliyan		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff do not follow masking protocols to prevent the spread of COVID

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced initial 10-day complaint visit to this facility. The LPA met with staff and explained the reason for the visit. The Administrator Mariam Kevliyan arrived shortly thereafter.

During today’s visit, the LPA conducted a physical plant tour at 8:50 a.m. and interviwed staff at 9:05 a.m.

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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 29-AS-20220606163942

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSISTED COMFORT HOME	FACILITY NUMBER: 197608534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 6/9/2022.
	8 9 10 11 12 13 14	Based on observations, the licensee did not comply with the section cited above, as staff were not wearing face masks in the facility, which poses an immediate personal rights risk to 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220606163942

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSISTED COMFORT HOME	FACILITY NUMBER: 197608534
	VISIT DATE: 06/08/2022

NARRATIVE

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Regarding the allegation: Staff do not follow masking protocols to prevent the spread of COVID
It was alleged that on 5/10/2022, a visitor came into the facility and observed that staff were not wearing face masks while in close contact with residents. During today’s visit, there were (6) residents present and (1) staff. Upon arrival the LPA observed Staff #1 (S1) not wearing a face mask. The LPA's observation supported claims from a credible witness that staff are not wearing masks when in close contact with residents raising concerns that staff are not following COVID-19 protocols. The LPA discussed masking guidelines with Administrator Mariam Kevliyan. Staff put masks on immediately upon the LPA’s observation and discussion with the Administrator. Based on the investigation, there is sufficient evidence to support the claim that staff are not following masking protocols. This allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

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