197608550-5-21-2026-29-AS-KLOZ-DUJ7TN-20260528215702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608550
Report Date: 05/21/2026
Date Signed: 05/21/2026 04:32:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/10/2025 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20250610125339

FACILITY NAME:	QUEEN COMFORT CARE CENTER, INC.		FACILITY NUMBER:	197608550
ADMINISTRATOR:	GOHAR AMBARTSUMYAN		FACILITY TYPE:	740
ADDRESS:	6534 MCLENNAN AVENUE		TELEPHONE:	(818) 469-2995
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	05/21/2026
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Nino Gelashvili.		TIME COMPLETED:	02:31 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not seek timely medical attention for resident resulting in hospitalization.
Facility staff were unable to answer communications from resident's representatives.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

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 6

Control Number 29-AS-20250610125339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUEEN COMFORT CARE CENTER, INC.	FACILITY NUMBER: 197608550
	VISIT DATE: 05/21/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the course of the investigation, on 08/25/2025, and 10/23/2025, interviews were conducted with Licensee Representative Nino Gelashvili. On 09/17/2025, interviews were conducted with R1’s responsible party. Facility records, along with hospital and hospice care records were also reviewed.
On the allegation ‘Facility staff did not seek timely medical attention for resident resulting in hospitalization’, it was alleged that the licensee did not call 911 following an incident that occurred approximately two weeks after R1 arrived when R1 needed to be transported to the hospital.
During the interview with the licensee, they acknowledged that on 10/10/2024, they observed R1 appearing weak due to barely eating. The licensee stated it was R1’s responsible party who did not want to call 911 at the time. Although, she called 911 and had R1 transported to the hospital after consulting the hospice care nurse. The licensee stated prior to this transfer, R1 was eating regularly and communicating with staff verbally. The licensee provided a copy of a text message thread that stated, “Please call. The whole family is saying to call 911. I don’t want to stay on my decision of not calling 911.” Although there is no indication of the date when this text message was sent nor any phone numbers verifying where the text message came from. During the interview with R1’s responsible party, they denied not wanting to call 911.
Record review reflects, R1 received a Comprehensive Nursing Assessment by hospice on 10/08/24. The resident was observed to be non-responsive, non-verbal, disorientated, and confused. It is noted that at the end of the visit, the patient was comfortable and safe. Hospital records reflect on 10/10/2024, the resident was hospitalized due to weakness and being non-verbal.
The Unusual Incident Report (LIC 624) submitted to the Department by the licensee indicates on 10/10/24, R1 was a “little weak” and ate “very little” of their breakfast. It was noted their vitals were okay, but hospice was still notified. When the hospice nurse arrived, they advised vitals were okay. It was noted that R1’s responsible party did not want R1 transported because they were “very angry” with the previous hospital. However, since the responsible party did not have Power of Attorney, 911 was called by the licensee.

Therefore, based on the information obtained during the course of the investigation, the allegation of ‘Facility staff did not seek timely medical attention for resident resulting in hospitalization’ is deemed Unsubstantiated at this time.

Continues on LIC 9099C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20250610125339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUEEN COMFORT CARE CENTER, INC.	FACILITY NUMBER: 197608550
	VISIT DATE: 05/21/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility staff were unable to answer communications from resident's representatives.
On the allegation that staff could not communicate with R1’s responsible representatives (RP), it is alleged that R1’s RP were not able to communicate with any of the care staff because none of them spoke English. To investigate the allegation LPA Urena interviewed staff and the Administrator. The staff's interview revealed that the staff have limited communication skills in English, however, the staff was able to answer the LPA's basic questions and was quick to call the Administrator to answer any additional questions. The Administrator reported that although the staff’s communication ability is limited, they understand English. Furthermore, the Administrator stated that they and the Licensee could have answered questions if needed. The RP reported speaking with the Administrator and expressing their concerns about R1’s condition. Furthermore, the R1’s representative communicated with the Administrator and discussed R1’s needs and need for treatment, as the concern of the RP was about R1’s declining health and change in condition.

Although the allegation may have happened or is valid, based on the interviews, the RP did have an option of communicating with the Administrator or Licensee to communicate their concerns on the change of condition of R1, consequently there is not sufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/10/2025 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20250610125339

FACILITY NAME:	QUEEN COMFORT CARE CENTER, INC.		FACILITY NUMBER:	197608550
ADMINISTRATOR:	GOHAR AMBARTSUMYAN		FACILITY TYPE:	740
ADDRESS:	6534 MCLENNAN AVENUE		TELEPHONE:	(818) 469-2995
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	05/21/2026
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Nino Gelashvili.		TIME COMPLETED:	02:31 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not properly assess resident prior to admission.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Urena met with the Licensee Nino Gelashvili. and explained the reason for the visit.

On 06/10/2025, the Woodland Hills North (WHN) Regional Office (RO) received the complaint C#29-AS-20250610125339 which was investigated by the Department.
On 06/12/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 24-hour visit to investigate the allegations listed above and met with the licensee. On this date the LPA collected documents pertinent to the investigation. During the course of the investigation, on 08/25/2025, and 10/23/2025, interviews were conducted with Licensee Representative Nino Gelashvili. On 09/17/2025, interviews were conducted with R1’s responsible party. Facility records, along with hospital and hospice care records were also reviewed.
Coninues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20250610125339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUEEN COMFORT CARE CENTER, INC.	FACILITY NUMBER: 197608550
	VISIT DATE: 05/21/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On the allegation that the facility staff did not properly assess resident prior to admission, it is the concern of the reporting party (RP) that when R1 initially arrived at the facility via ambulance to be admitted at the facility, R1 appeared very ill, almost “on the verge of death, and the RP felt that the staff should never have allowed R1 to remain at the facility and should have had R1 transported to a hospital. During interviews, Nino Gelashvili, the licensee acknowledged that when R1 arrived at the facility R1 indeed appeared very “weak,” and was also nonresponsive (not verbally communicating). Licensee also acknowledged she had not seen R1 prior to their arrival and admission at the facility; however, licensee had been in communication with R1’s social worker at the hospital in Stockton prior to R1’s arrival. Licensee stated that prior to R1’s arrival, the social worker sent to the licensee R1’s “Physician Report” signed by a doctor on 09/23/2024. Licensee stated that the Physician’s Report indicated that R1 was “independent,” which the licensee observed was not the case when R1 arrived.

Furthermore, based on the record review of the “Physicians Report”, the report indicated R1 was “unable to care for self” due to “Confusion.” It did indicate that R1 was able to bathe, dress, feed, and toilet themselves. However, it also indicated that R1 required “assistance”, and that that R1 was not able to transfer themselves to and from her bed, and that R1 was indeed “bedridden” due to both their “physical” and “mental” condition. It was also accurately indicated in R1’s “Physician’s Report,” that R1 indeed required “assistance” when it came to their ADL’s (Activities of Daily Living).

The licensee stated that R1 arrived at the facility with no discharge papers or R1 medication orders signed by a doctor, so the licensee was unable to order any medication for R1. Licensee acknowledged the
only documents she received for R1 prior to their arrival and admission at the facility was R1’s “Physician’s
Report” and “list” of medications

Therefore, based on the information obtained during the course of the investigation, the allegation of
‘Facility staff did not properly assess resident prior to admission’ is Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted. A copy of the report and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20250610125339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 05/21/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/29/2026 Section Cited CCR 87457(a)(c)	1 2 3 4 5 6 7	Pre-Admission Appraisal (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee stated that they will conduct a pre-admission at all times. Licensee will review regulation for understanding and will email the LPA a letter self-certifing the understanding that they read the regulation and understand the importabce of conductuing the Pre-admission appraisal.
	8 9 10 11 12 13 14	Based on observation: The Licensee did not comply with this regulation as R1 was not propretly assessed and an Apparaisal was not conducted by the licensee to ensure that R1's needs could be met at the facility.	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.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6