<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608550
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:20:10 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
10/14/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20221014141629
FACILITY NAME:QUEEN COMFORT CARE CENTER, INC.FACILITY NUMBER:
197608550
ADMINISTRATOR:GOHAR AMBARTSUMYANFACILITY TYPE:
740
ADDRESS:6534 MCLENNAN AVENUETELEPHONE:
(818) 469-2995
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 5DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gohar Ambartsumyan - Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not wearing PPE
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint investigation for the allegation listed above. Upon arrival LPA met with Administrator Gohar Ambartsumyan and explained the reason for the visit. At approximately 9:30am, LPA conducted physical plant, interviewed staff and residents as well as reviewed and obtained copies of pertinent documents relevant to the investigation.
It was alleged that facility staff are not wearing PPE. Regional office received information from a credible witness that while visiting the facility, they observed that staff were not wearing masks. Upon arrival to the facility, LPA observed all staff wearing masks. However, LPA interview with the licensee, Administrator and Staff 1 (S1) revealed they recently had a visit from an outside agency who observed S1 and other staff not wearing a mask while working with the residents. Based on information gathered during the visit, the allegation of "Staff are not wearing PPE" is deemed SUBSTANTIATED at this time.

Citations Issued.  See LIC 9099D.  Appeal Rights discussed. Exit interview conducted and copy of the report issued and emailed to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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 2
Control Number 29-AS-20221014141629
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: QUEEN COMFORT CARE CENTER, INC.
FACILITY NUMBER: 197608550
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2022
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: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations...

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to advised staff on wearing masks at all times inside the facility and conduct a training on CA Dept of Public Health Guidance for the use of face coverings and COVID-19 screening protocols and submit proof to LPA via email by end of day 10/18/2022.
8
9
10
11
12
13
14
Based on interviews, the Licensee did not ensure the personal rights of persons in care to live in a safe, healthy, and comfortable home as staff did not wear face coverings at all times while inside the facility, which poses an immediate health and safety 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2