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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608939
Report Date: 05/21/2021
Date Signed: 04/28/2022 04:36:32 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2020 and conducted by Evaluator Aja Richardson
COMPLAINT CONTROL NUMBER: 29-AS-20201019082739
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: 5DATE:
05/21/2021
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Slava Shcherba, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Residents needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced subsequent visit regarding the above allegation. LPA arrived at the facility at 9:50 am and was greeted by staff Carolyn Avakian and the Administrator Slava Shcherba arrived shortly after. LPA explained the reason for the visit.

Regarding the above allegation there are concerns that Resident #1 (R1) had pressure injuries that were not appropriately cared for while R1 lived at the facility. To investigate this allegation LPA conducted intervews with R1 on 3/3/21 at 1:34 pm via telephone as R1 no longer lives at facility. On 5/21/2021 at 11:45 am, LPA reviewed R1's file including hospital discharge papers dated 10/3/2020, Physician Report, and Needs and Services. According to interviews with R1 and record review R1 moved into facility on 10/3/20 with a Stage 1 pressure injury. Based on interviews with facility Administrator on 5/21/21 at 11: 50 am, during the time R1 lived at the facility from 10/3/20 to 10/27/20, R1 was not receiving wound care from a skilled professional due to R1's behaviors and R1 not wanting to live at the facility.
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: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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 4
Control Number 29-AS-20201019082739
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
VISIT DATE: 05/21/2021
NARRATIVE
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 Based on interviews and record review R1 needs were not being met as Stage 1 and Stage 2 pressure injuries require care from an appropriately skilled professional. This allegation is Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. The report was signed, however a copy of the signed report was emailed, along with the appeal rights.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20201019082739
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: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2021
Section Cited
CCR
87631(a)(1)
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Healing Wounds: licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:
When care is performed by or under the supervision of an appropriately skilled professional.
This requirement was not met as evidenced by:
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1. R1 no longer resides at the facility however the Administrator agreed to review regulation 87631(a)(1) and provide training to all staff.
2. Include date of training, signature from participating staff and topic reviewed and submit to licensing by POC due date.
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Based on interviews and record review, facility staff failed provide R1 care from a skilled professional which poses an immediate health and safety risk to R1.
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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: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
10/19/2020 and conducted by Evaluator Aja Richardson
COMPLAINT CONTROL NUMBER: 29-AS-20201019082739

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: DATE:
05/21/2021
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff would not give resident the ombudsman phone number
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced subsequent visit regarding the above allegation. LPA arrived at the facility at 9:50 am and was greeted by staff Carolyn Avakian and the Administrator Slava Shcherba arrived shortly after. LPA explained the reason for the visit.

Allegation: Staff wound not give resident ombudsman phone number. To investigate this allegation, LPA conducted interview with Resident #1(R1) on 3/3/2021 at 1:34 pm. On today's visit between 10 am and 12 pm, LPA interviewed other residents in care, resident relative, staff and facility Administrator. According to the interviews conducted there are no concerns with facility witholdng the ombudsmen telephone number. On 5/21/2021, LPA observed the number is also posted at the facility. Based on this informaton there is insuffiicent evidence that staff witheld ombudsman telephone number. This allegation is Unsubstantiated at this time.

Exit interview conducted. Report emailed to Administrator.
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: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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 4