197608972-10-12-2021-29-AS-DPEA-CSBMZV-20230530100344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608972
Report Date: 10/12/2021
Date Signed: 10/12/2021 06:28:45 PM

Unsubstantiated

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
10/04/2021 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20211004144804

FACILITY NAME:	ANTHEM SENIOR CARE		FACILITY NUMBER:	197608972
ADMINISTRATOR:	GHAZARYAN, SOFIA		FACILITY TYPE:	740
ADDRESS:	12813 FRIAR STREET		TELEPHONE:	(818) 445-0993
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Sofia Ghazaryan, Administrator		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff did not ensure that resident has privacy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced initial 10-day complaint inspection. The LPA met with Administrator Sofia Ghazaryan at 9:05 a.m. and explained the reason for the visit.
During today’s visit, the LPA conducted a physical plant tour from 10:06 a.m. until 10:22 a.m. to ensure there are no health and safety hazards. From 9:44 a.m. until 10:06 a.m., the LPA conducted an interview with the administrator. Between 9:12 a.m. and 2:20 p.m., the LPA interviewed facility residents. From 11:14 a.m. until 11:54 a.m., the LPA interviewed resident family member(s). Between 12:05 p.m. and 3:00 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 4:53 p.m. until 6:15 p.m., the LPA conducted a Medication assessment with the administrator Sofia Ghazaryan. All medication was placed back into its original containers.

Continue on LIC 9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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 29-AS-20211004144804

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: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
	VISIT DATE: 10/12/2021

NARRATIVE

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Regarding the allegation, ‘Staff did not ensure that resident has privacy’, the complainant’s concern is that residents have a lack of privacy, as shared rooms do not have curtains separating each resident’s area in bedrooms.

During the investigation, LPA Walker conducted a physical plant tour, records reviewed, interviewed facility residents, and the administrator. Physical plant tour revealed that two (2) out four (4) bedrooms are shared rooms, and no curtains are placed dividing any living spaces. Record review revealed that resident’s in shared rooms agreed in Admissions agreement to share the living space with another resident during duration of stay. No indication in writing on the Admission’s agreement as to curtains being required as divider for personal privacy. Interview with the administrator revealed that the administrator has not provided any indication to families or facility residents that shared rooms will be divided by means of curtains. Interviews with the facility residents revealed that residents feel they do have privacy in their living spaces.

Based on physical plant tour, records reviewed, interviews with facility residents, and the administrator, there is insufficient evidence to support the allegation ‘Staff did not ensure that resident has privacy.’ Therefore, this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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