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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608678
Report Date: 06/15/2022
Date Signed: 06/15/2022 12:05:26 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
06/03/2022 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20220603115538
FACILITY NAME:HARTLAND CARE, INC.FACILITY NUMBER:
197608678
ADMINISTRATOR:ANI MAKARYANFACILITY TYPE:
740
ADDRESS:8224 ZELZAH AVENUETELEPHONE:
(818) 697-5363
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 6DATE:
06/15/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Dianna MakaryanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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At approximately 9:55 a.m. on 06/15/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with staff and later administrator and disclosed the reason for the visit. Regarding the allegation above, it was alleged staff #1 (S1) pushed resident #1 (R1) out of the restroom. To investigate the allegation, LPA interviewed R1 and the administrator on 06/10/2022 from 8:00 a.m. to 1:00 p.m. and interviewed S1 on 06/15/2022 at 11:10 a.m. LPA also conducted a record review on 06/10/2022 at 12:40 p.m. From interviews, it was revealed that S1 pinched the sleeve of R1 to remove them from the restroom. Based on LPA’s interviews the preponderance of evidence standard has been met. The above allegation is therefore deemed to be SUBSTANTIATED at this time. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099-D.

Exit interview conducted. Copy of report and appeal rights provided.
Substantiated
Estimated Days of Completion: 20
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
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 31-AS-20220603115538
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: HARTLAND CARE, INC.
FACILITY NUMBER: 197608678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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Licensee will provide an in-service training on the cited section to all staff and submit proof to LPA by the POC due date.
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Based on interviews, the licensee did not comply with the section cited above with resident #1 (R1) which poses a potential health, safety or personal rights risk to persons in care.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
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