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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609030
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:01:33 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
05/01/2023 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20230501103125
FACILITY NAME:NEW HOPE BOARD AND CAREFACILITY NUMBER:
197609030
ADMINISTRATOR:MODINA, THERECEFACILITY TYPE:
740
ADDRESS:19435 STRATHERN STREETTELEPHONE:
(747) 237-2337
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 3DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Diane KerapetyanTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Insufficient staffing to meet residents' needs.
Facility is operating beyond the terms and conditions of the license.
Staff failed to administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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On 5/9/2023, Licensing Program Analyst (LPA) Melissa Ruiz and Licenisng Program Manager (LPM) Nichelle Gillyard arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPA and LPM were greeted by a staff member (S1). LPA later met with Administrator Diane Karepetyan and Licensee Therece Modina. An entrance interview was conducted and the purpose of the visit was explained.

Insufficient staffing to meet residents' needs.

Upon arrival, at 8:30 a.m., LPM Gillyard and LPA Ruiz observed one staff (S1) providing direct care to 3 out of 3 residents. S1 was observed to be providing care and supervision. LPM Gillyard had to prompt S1 to make breakfast for all residents. The Administrator stated that she is usually here every morning to assist S1 with morning tasks, however Administrator arrived around 9:00 a.m. Due to LPA and LPM observation, this allegation is deemed substantiated at this time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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 6
Control Number 31-AS-20230501103125
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: NEW HOPE BOARD AND CARE
FACILITY NUMBER: 197609030
VISIT DATE: 05/09/2023
NARRATIVE
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Allegation: Facility is operating beyond the scope of the licensee.

To investigate this allegation LPM and LPA conducted interviews with Therece Modina, (previous Administrator and current Licensee) and current Administrator Diana Karapetyan at approximately 9:35 am. LPM requested and reviewed the current property deed and current lease dated 04-15-2023. LPM/LPA observed a general letter of intent to sell the facility was dated March 27, 2023. As of April 1, 2023, the business was sold to now current Administrator Diana Karapetyan. According to Ms. Karapetyan the application for licensure was submitted to the department Thursday May 4, 2023. LPM requested and reviewed the application. According to Ms. Karapetyan, Therece Modina is still the licensee until the application is approved and a license is issued. Mrs. Modina acknowledged to be the current license. However, during the investigation, it was discovered that Mrs. Modina lost control over property as she no longer has a lease, therefore there is no license. Instead, a lease was given to the new Licensee and Administrator Diana Karapetyan. There was no lease back between Mrs. Karapetyan and Modina to give control back to current licensee, Mrs. Modina. The lease back is required for the current licensee(197609030) that Mrs. Modina is to maintain the license during the application process for the new licensee. Therefore, the allegation, Facility is operating beyond the scope of the licensee to be substantiated. Citation and appeal rights issued..

Allegation: Staff failed to administer resident's medication as prescribed.

At 12:30 p.m. LPA and LPM conducted a random medication count for R1 with the Administrator. There were four different medications counted, selected at random. Out of the four medications counted, all four were either short pills or had pills missing, per the information listed on the Centrally Stored Medication and Destruction Record Log and medication instructions on the bottles. During record review, LPA and LPM observed a PRN order for R1 however there was no log or records to log when PRN was given, per a doctor's instruction due to R1 being unable to make that determination. Additionally, LPA collected the Centrally Stored Medication and Destruction Record, PRN Authorization Letter, and the Medication Administration Record (MAR).

Deficiencies issued per CA Code of Regulations, Title 22. See LIC9099D with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20230501103125
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: NEW HOPE BOARD AND CARE
FACILITY NUMBER: 197609030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
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Licensee/administrator shall provide an updated LIC500 to reflect staff and staff hours. Additionally, Administrator shall provide a hiring plan for new or changing staff. Within 30 days of this report, the Administrator will submit a new LIC500 to reflect updates to staffing.
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Based on LPA and LPM observation, the licensee/administrator did not ensure that there was sufficient staff to assist with direct care or supervision to 3 out 3 residents.This poses an immediate health, safety or personal rights risk to persons in care due to dementia residents in care.
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Type A
05/11/2023
Section Cited
HSC
1569.191(e)
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§1569.191 Sale of licensed facility; resulting issuance of new license; procedure (e) If the parties involved in the transfer of the property and business fully comply with this section, then the transfer may be completed and the buyer shall not be considered to be operating an unlicensed facility while the department makes a final determination on the application for licensure.

This requirement is not met as evidenced by:
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The new owner will provide CCLD a written statement indicating that they will provide the current licensee a lease back agreement by the POC due date. Within a week from this report, the new owner will provide the lease back agreement copy to CCLD.
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Based on LPA and LPM record review and interviews conducted, the current licensee Therece Modina gave up/lost control of this property before the new owner was licensed. New owner holds the current lease. New owner did not lease back to There Modina, current licensee. This poses an immediate health, safety or personal rights risk to persons in care due to dementia residents 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
05/01/2023 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20230501103125

FACILITY NAME:NEW HOPE BOARD AND CAREFACILITY NUMBER:
197609030
ADMINISTRATOR:MODINA, THERECEFACILITY TYPE:
740
ADDRESS:19435 STRATHERN STREETTELEPHONE:
(747) 237-2337
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 3DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Diane KerapetyanTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is in disrepair.
Staff failed to provide adequate food service.
INVESTIGATION FINDINGS:
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LPM Nichelle Gillyard and LPA Melissa Ruiz responded to the facility to conduct an investigation at 8:30 am. Upon arrival team was greeted by staff Luiza Sukasyan. LPM requested that the Administrator be contacted. Current Administrator Diana Karapetyan appeared for the visit. The complainant’s concern is that the facility was in disrepair, more specifically that the Air Conditioner was not working.

LPM conducted a physical plant tour and interviews with the Administrator to address this allegation at 10 am. LPM observed the temperature of the home to be 71 degrees F which is within regulation. At 10:05 am the air conditioner was turned on and was observed to be operational. Interview indicates that approximately 3 weeks ago the air conditioner was not working. The facility temperature was 82 degrees F, which is within regulation. The administrator called the owner for repair. In the meantime, the Administrator utilized fans to cool off the facility. The air conditioner was reset and operational by the end of the day. (cont. on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20230501103125
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: NEW HOPE BOARD AND CARE
FACILITY NUMBER: 197609030
VISIT DATE: 05/09/2023
NARRATIVE
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Therefore, after review of the information gathered the allegation is unsubstantiated at this time. It is reasonable to believe that things in the facility will breakdown. It is the responsibility that the Administrator/Licensee address the issues within a reasonable time as it appears that the Administrator/licensee has done so. LPM did not observe anything in disrepair in the facility.

Staff failed to provide adequate food service.

To investigate this allegation, LPA observed staff prepare meals for 3 out of 3 residents in care. LPA observed toast, egg, yogurt, a protein shake, and tea or coffee being served to all residents. Additionally, LPA interviewed a R2’s friend at 9:30 a.m., who was present at the time of this visit. R2’s friend stated they were happy with the food service and meals R2 had been receiving. R2’s friend also confirmed that the breakfast we observed was the standard food provided. Regarding food service for two previous residents, LPA interviewed the Licensee at 10:45 a.m., and the Licensee stated that there was no special diet in place, just special requested from two (2) previous residents. LPA was unable to conduct any record review for 2 previous residents to corroborate this statement, as their complete records were removed by their family member. At 12:15 p.m., LPA and LPM observed lunch being prepared and served for 2 out of 2 residents at the facility. Lunch consisted of vegetables, ground meat, and mashed potatoes. Due to LPA and LPM observations and interviews conducted, the allegation is unsubstantiated at this time.

Appeal rights issued. Report signed and delivered. Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20230501103125
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: NEW HOPE BOARD AND CARE
FACILITY NUMBER: 197609030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
87465(a)(d)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:
(1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
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The Administrator shall provide proof of scheduling medication training for themselves and staff, per regulation. The Administrator will have one week from this report to submit records of training for everyone conducted.
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Based on a randomized medication count conducted, 4 medications for R1 were observed to be missing or over the pills designated on the pill bottles or medication log. This poses an immediate health, safety or personal rights risk to residents 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6