197608986-6-21-2023-29-AS-DPEA-CT8P4N-20230628105926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 06/21/2023
Date Signed: 06/21/2023 06:57:40 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
01/31/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20230131164509

FACILITY NAME:	AGE WELL ASSISTED LIVING FACILITY		FACILITY NUMBER:	197608986
ADMINISTRATOR:	SARKIS DOVLATYAN		FACILITY TYPE:	740
ADDRESS:	15149 SYLVAN STREET		TELEPHONE:	(818) 666-1665
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY:	6	CENSUS: 6	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sarkis Dovlatyan - Administrator		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility.

Staff not properly managing resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA)'s Brian Balisi and Zabel Chochian conducted a subsequent complaint visit to further investigate the allegations listed above and issue final report. Upon arrival, LPAs met with staff Zhyparkul Mursamambetova and explained the reason for the visit. Administrator Sarkis Dovlatyan arrived shortly after.
On 1/31/2023, the Department receive a complaint alleging that Resident #1 (R1) had eloped from the facility six (6) times. In addition, it was further alleged that facility staff reported that R1s medication (name of med) needs to be refilled. However, per the RP, the medication staff referred to was not prescribed to R1.

On 02/02/2023, the initial complaint visit was conducted by LPA Balisi approximately between 9:30 a.m. – 11:30 a.m. During the visit, LPA conducted physical plant tour, interviewed residents, staff, responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 02/15/2023, Investigation Branch (IB) Special Investigator Eleza Jackson was assigned to obtain all medical and police records pertaining to R1.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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-20230131164509

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: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
	VISIT DATE: 06/21/2023

NARRATIVE

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Continued from 9099
During today’s visit at approximately 9:45 a.m., LPAs conducted physical plant, interviewed residents, and staff, as well as reviewed and obtained additional pertinent documents relevant to the investigation. Medication audit was also conducted today with Hospice Nurse who is associated with Sweet Touch Hospice and Silver Years Healthcare, approximately between 1 p.m. – 2 p.m. Also, during the visit LPAs reviewed all medical and police records obtained.

Following is a summary of the investigation:

Allegation 1) Lack of supervision resulting in resident eloping from facility.

It was reported that due to lack of supervision R1 eloped from the facility, it was further alleged that R1 eloped multiple times. Information gathered during the investigation reflected that R1 was admitted to the facility on 12/19/2022. During the initial 10-day complaint visit on 02/02/2023, LPA conducted interview with Staff 1 (S1), who revealed R1 did in fact elope from the facility several times. S1 further explained that each time R1 eloped, S1 was servicing another resident. S1 would then contact the family member of R1 to locate R1 via GPS tracking on their phone. During a visit on a separate investigation on 02/07/2023, it was discovered that R1 had eloped again on 02/06/2023 and was struck by a moving vehicle. R1 was admitted to Northridge Hospital and did not return to the facility. Medical records obtained and reviewed revealed R1 sustained multiple rib fractures and hematoma to the right side of the forehead. Based on information obtained during the investigation, the department has sufficient evidence to determine R1 eloped from the facility multiple times due to lack of supervision and as a result sustained serious injury. Therefore, the allegation that lack of supervision resulted in R1 eloping from the facility is deemed SUBSTANTIATED at this time.

Allegation 2) Staff not properly managing resident's medication:
It was reported that staff are not properly managing resident’s medication. It was reported that S1 did not have knowledge of the medication prescribed to R1 and requested the family to refill a medication not prescribed to R1. Interviews conducted and records reviewed during the initial visit on 02/02/2023, revealed that R1’s responsible party was requested by S1 to order more Lexapro for R1. Review of R1’s Centrally Stored Medication and Destruction Record (CSMDR) revealed Lexapro is not listed on R1’s list of medications.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20230131164509

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: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
	VISIT DATE: 06/21/2023

NARRATIVE

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Continued from 9099-C

The responsible party corrected S1 and stated that R1 is not prescribed Lexapro. Interviews, medication audit with Hospice nurse and file review conducted on 06/21/23 between 9:45 a.m. – 3 p.m., revealed five (5) out of five (5) resident medications reviewed were observed to be in bubble packs, however LPAs observed the medications were punched out in what appeared to be a random order and was not following any cycle of medications. There were no CSMDR on site to review. LPA’s interview with Staff 2 (S2) regarding medication did not reflect that S2 was properly trained to administer medication to residents in care. Based on information obtained during the investigation, the department has sufficient evidence to determine that staff are not administering medication properly. Therefore, the allegation that staff are not properly managing resident’s medication is deemed SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today due to the injury of R1. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

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. A copy of the report and appeal rights were provided

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20230131164509

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: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/22/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic services: Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee has since hired new and additional caregivers. Licensee also agreed to submit a Statement of Understanding demonstrating full understanding of the regulation cited and send to LPA via email by EOD 06/22/2023.
	8 9 10 11 12 13 14	Based on interviews and records review the lack of care and supervision resulted in R1 eloping from the facility on multiple occasions and sustaining serious injuries. This poses as an immediate health and safety risk for the residents in care.	8 9 10 11 12 13 14
Type B 06/30/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee has agreed to hold a staff meeting to conduct training and review regulation. Licensee agreed to submit sign-in sheet of those who attend and submit a statement of understanding demonstrating full understanding of the regulation cited and send to LPA via email by 06/30/2023.
	8 9 10 11 12 13 14	Based on interviews and records reviewed there were no centrally stored medication records to review and bubble packs for (5) out of the (5) residents appeared to not be dispensed properly. This poses a potential health and safety rise for the residents in care	8 9 10 11 12 13 14

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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