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13 | An Informal Meeting was held at the Monterey Park Adult and Senior Care (CCLD) Regional Office to deliver findings on the above allegation and discuss the Trust Audit completed on 3/8/2022 by CCLD Audit Section. The purpose of the meeting was explained to Licensee Tina Arutyunyan and Assistant Administrator Akop Ekimyam. Attendees present were: CCLD Regional Manager Araceli Ramirez, Licensing Program Manager (LPM) Lisa Hicks, Licensing Program Analysts (LPAs) Noemi Galarza, and Mary Flores, Woodland Hills ASC staff, and Auditor Jacqueline Juarez.
The investigation consisted of the following: On 9/1/2021, LPA inspected the facility and interviewed staff (S2) & residents (R1-R5). R6 was not interviewed due to cognitive impairment. The following documents were obtained: ID/Emergency Information, Admission Agreements, Appraisals, Physician's Report, LA County Department of Mental Health/Brilliant Corners Flexible Housing Subsidy Pool (FHSP) Program Agreement. Personal & Incidental (P &I) records/purchase receipts were not observed or obtained. On 9/10/2021, Licensee was interviewed telephonically and was asked to submit the facility’s business account bank statements and proof of Surety Bond. On 9/20/2021, an Audit request was initiated. On 11/3/2021, a MS Teams meeting was held with Licensee, CCL Audit Manager Jaqueline Juarez, and Regional office staff to discuss LA County Department of Health Services [Housing for Help], Brilliant Corners program and resident P & I money management. |
| Substantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | Allegation: "Financial Abuse". It is alleged that Licensee misappropriated Personal & Incidental (P&I) funds of two (2) residents (R1 & R2), who are enrolled in the LA County Department of Health Services/Department of Mental Health [Housing for Help] Enriched Residential Care (ERC) program, that contracts a non-profit organization called Brilliant Corners. The Department of Health Services places persons in licensed facilities. Brilliant Corners is the payee and is responsible for making rent payments and issuing P & I money. Recipients of the program are usually homeless, do not qualify for Social Security benefits, and are provided wrap-around services by Brilliant Corners. Brilliant Corners issues a lump sum payment to the facility for resident participants. The Brilliant Corners Agreement is signed by the Licensee and specifies how the amounts should be allocated (Rent, Personal & Incidental expenses, and Enhanced Services).
Resident (R1) moved in to the facility on 1/6/2021 and resident (R2) moved in on 7/2/2021. Both residents receive $138.00 a month of P & I money. On June 2, 2021, the Department of Health Services conducted a random Quality Assurance audit visit. It was noted that personal and incidental monies were not documented or accounted appropriately. Licensee Tina Arutyunyan was informed of the deficiency and submitted hand-written amounts on the Plan of Correction documents. The receipts documented excess expenditures of items never requested or received by residents (R1 & R2). The items listed do not have resident’s initials or original receipts to support transactions. It is clear from the documents that they are prepared after the fact, as they are dated with 8/11/2021 as a plan of correction. There were no supporting original receipts for items allegedly purchased for the residents with the P & I monies. P & I is strictly to be used for residents personal spending money.
On 9/1/2021, LPA interviewed residents (R1-R5). Residents (R1 & R2) confirmed they have not been given P & I monies. Resident (R2) stated Licensee has not given the resident any allegedly purchased items like an electric razor; resident only owns a regular razor, and a nail trimming services have not been received. P & I records/purchase receipts were not observed in resident files during the initial complaint visit. Ms. Arutyunyan was not present during the initial complaint visit and was interviewed on 9/10/2021. Licensee denied managing or spending resident (R1 & R2’s) P & I money. She stated that resident (R1) is a smoker and “all the P & I money goes to cigarettes.” On November 3, 2021, the licensee was notified and told by CCLD Auditor Jacqueline Juarez how to keep records of and distribute P & I amounts. Per record review, Licensee Tina Arutyunyan provided Department of Health Services and Community Care Licensing inaccurate information and documentation about the distribution of P & I monies and the money was spent.
See LIC 9099C for report continuation.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/10/2022
Section Cited
CCR
87217(c)(1) | 1
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7 | Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff. Cash resources include but are not limited to... personal and incidental need allowances from funding sources such as SSI/SSP. This requirement was not met evidenced by: | 1
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7 | Licensee agrees to:
1. Pay back residents (R1 & R2) all P & I amounts due. Licensee owes:
Resident (R1) $1,518.00
Resident (R2) $690.00.
2. Submit proof (bank statements) that the amounts due were issued to R1 & R2. |
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14 | Based on the Trust Audit report, record review, and interviews conducted the findings indicate Licensee did not distribute P & I funds to residents (R1 & R2), and did not keep proper records of funds entrusted to her. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
05/10/2022
Section Cited
CCR
87217(e) | 1
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7 | Safeguards for Resident Cash, Personal Property, and Valuables. Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables... | 1
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7 | Licensee agrees to deposit residents' P & I funds into a bank trust account. Facility bank account should not have any residents' monies.
Provide copies of bank statements showing
P & I funds have been deposited into a trust account. |
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14 | This requirement was not met evidenced by: Based on Trust Audit report and record review Licensee is commingling facility funds with personal and incidental funds. Facility bank statements were obtained. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/10/2022
Section Cited
CCR
87216(a) | 1
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7 | Bonding. Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. The amount of the bond shall be in accordance with the following schedule: Total Safeguarded Per Month- Bond Required $750 or less= $1,000, $751 to $1,500= $2,000
$1,501 to $2,500 =$3,000. | 1
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7 | Licensee agrees to submit a copy of the Surety Bond by POC due date.
NOTE: The Surety Bond should cover the facility and not the corporation. |
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14 | This requirement was not evidenced by:
Based on record review and interviews conducted Licensee acknowledged that a Surety Bond was not in place on 9/1/2022. The bond provided covers the corporation and does not cover each license. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
05/10/2022
Section Cited
CCR
87405(d)(2-3)(5) | 1
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7 | Administrator - Qualifications and Duties.The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records. (5) Good character and a continuing reputation of personal integrity.
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7 | Licensee/Administrator will schedule vendorized training related to the cited section as well as all other sections cited on this report.
See below: |
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14 | This requirement was not evidenced by:
Based on the Trust Audit report and record review the findings indicate Licensee failed to maintain financial records; and provided DHS and CCL inaccurate documentation and information. | 8
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14 | Licensee will attend continued education classes provided for Administrators. By POC due date, the Licensee will secure the appointment to attend the classes and inform CCL about the attendance. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/10/2022
Section Cited
CCR
87217(b) | 1
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7 | Safeguards for Resident Cash, Personal Property, and Valuables. (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. | 1
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7 | Licensee agrees to give residents receipts for all articles or cash resources, and keep proper documentation for expenditures.
Submit a written plan addressing facility procedures and protocols. |
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14 | This requirement was not met evidenced by:
The Trust Audit findings revealed that Licensee failed to document expenditures of items purchased with P & I monies. Hand written amounts were submitted without original receipts. Receipts were prepared after the fact dated 8/11/21. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
05/10/2022
Section Cited
CCR
87215 | 1
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7 | Commingling of Money. Money and valuables of residents entrusted to the licensee of one community care facility licensed under a particular license number shall not be commingled with those of another residential care facility for the elderly of a different license number, regardless of joint ownership. | 1
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7 | Licensee agrees to provide a copy of the bank statement showing P & I funds have been deposited into a trust account.
Submit by POC due date. |
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14 | This requirement was not evidenced by:
Based record review and interview condcuted during the audit investigation the Licensee failed to maintain accurate financial records; and provided DHS and CCL inaccurate documentation and information. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
04/27/2022
Section Cited
CCR
87207 | 1
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7 | False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement is not met as evidenced by: | 1
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7 | Licensee/Administrator will schedule vendorized training related to the cited section as well as
87408: Denial or Revocation of a Certificate
87777: Exclusions
Personal Rights.
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14 | Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by providing inaccurate information and documentation to Department of Health Services and Community Care Licensing. This poses an immediate health, safety or personal rights risk to persons in care.
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14 | Verification of scheduled training with the trainers credentials will need to e submitted by 4/29/2022 and completed by 5/13/2022. |
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