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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608939
Report Date: 03/03/2021
Date Signed: 03/03/2021 03:51:47 PM



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
02/22/2021 and conducted by Evaluator Aja Richardson
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210222161157
FACILITY NAME:AAA JERUSALEM STARFACILITY NUMBER:
197608939
ADMINISTRATOR:VIACHESLAV SHCHERBAFACILITY TYPE:
740
ADDRESS:5945 CAPISTRANO AVENUETELEPHONE:
(818) 888-1706
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 3DATE:
03/03/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Slava Schcherba and Vardan AyrapetyanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff failed to conduct assessment before resident moved in facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Aja RIchardson initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Slava Shcherba and the licensee Vardan Ayrapetyan.

To investigate this above allegation on 3/3/2021, LPA conducted interviews with the Administrator at 11:20 am, licensee at 11:40 am, and Resident #1 (R1) at 1:20 pm. Based on interviews conducted a preadmission appraisal was not conducted before resident moved into the facility. The Administrator stated appraisal was completed once R1 moved in. Based on the above information this allegation is Substantied.
Exit Interview Conducted. Deficiencies Cited. Appeal Rights Given. Report Emailed to Administrator for SIgnature.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
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 29-AS-20210222161157
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: AAA JERUSALEM STAR
FACILITY NUMBER: 197608939
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2021
Section Cited
CCR
87457(a)(1)(2)
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87457: Preadmission Appraisal: General
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..the placement to make an informed decision regarding admission. This requirement is not met as evidenced by...
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Administrator will review regulation and submit a letter of understanding by POC due date.
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Based on interviews conducted facility Administrator, Licensee, and Resident #1, failed to conduct a pre admission appraisal which posed a potential health and safety risk to Resident #1.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
02/22/2021 and conducted by Evaluator Aja Richardson
COMPLAINT CONTROL NUMBER: 29-AS-20210222161157

FACILITY NAME:AAA JERUSALEM STARFACILITY NUMBER:
197608939
ADMINISTRATOR:VIACHESLAV SHCHERBAFACILITY TYPE:
740
ADDRESS:5945 CAPISTRANO AVENUETELEPHONE:
(818) 888-1706
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 3DATE:
03/03/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Slava Schcherba and Vardan AyrapetyanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Facility staff took resident checkbook to write check for resident rent without authorization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Aja RIchardson initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Slava Shcherba and the licensee Vardan Ayrapetyan.

To investigate this above allegation on 3/3/2021, LPA conducted interviews with the Administrator at 11:20 am, licensee at 11:40 am, and Resident #1 (R1) at 1:20 pm. Based on interviews conducted with the Administrator and Licensee they did not have access to resident checkbook and have never used R1's check to write a check. R1 does not have a copy of check or documentation that the check was written. At this time there is insufficient evidence that the Licensee or Administrator took R1's check to pay R1's facility rent. This allegation is Unsubstantiated at this time.
Exit Interview Conducted. Report emailed to Administrator for Signature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3