197609108-8-9-2021-29-AS-JAPL-C5QV2B-20210809160253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609108
Report Date: 08/09/2021
Date Signed: 08/09/2021 11:06:27 AM

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
06/04/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200604144340

FACILITY NAME:	HERRIK HOME LLC		FACILITY NUMBER:	197609108
ADMINISTRATOR:	MELIKYAN, MARIA		FACILITY TYPE:	740
ADDRESS:	13303 REEDLEY ST		TELEPHONE:	(818) 644-1008
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	0	CENSUS: 0	DATE:	08/09/2021
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:			TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care
Facility staff did not dispense medication as prescribed
Facility staff did not ensure that resident's blood sugar was monitored

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith initiated a subsequent complaint investigation to issue findings for the allegations above. The LPA attempted to speak with former licensee Arutyun Sayan over the phone to issue the findings, yet they were unavailable. This facility is no longer operational, and the license was forfeited on 3/8/2021.

On 6/4/2020, the Department received a complaint, alleging the above allegations. Community Care Licensing Division’s Investigations Branch (IB) Investigator Dennis Douglas was assigned to the case. Investigator Douglas attempted a facility visit on 6/12/2020; interviewed staff from a home health agency on 6/12/2020, 6/22/2020 and 7/16/2020; interviewed a collateral placement agency representative on 6/19/2020 and 6/23/2020; reviewed medical documents on 6/26/2020, 7/15/2020, 7/29/2020; interviewed facility staff on 7/17/2020, 8/20/2020 and 8/21/2020; and, interviewed R1 on 7/29/2020. The LPA interviewed R1 on 7/19/2021 at 2:15 p.m.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

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 8

Control Number 29-AS-20200604144340

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: HERRIK HOME LLC	FACILITY NUMBER: 197609108
	VISIT DATE: 08/09/2021

NARRATIVE

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Regarding the allegation: Resident sustained multiple pressure injuries while in care
It was alleged that Resident #1 (R1) developed multiple pressure injuries. R1 was admitted to the facility on 3/4/2020 and interviews and records review confirmed that R1 only had a pressure sore on their buttocks prior to being admitted. However, a review of the Plan of Care assessment completed by home health on 3/9/2020 identified unstageable pressure injuries on R1’s left and right heel, and a stage 2 pressure injury on R1’s left buttock. A nursing visit on 3/12/2020 noted that R1’s pressure injury on the left buttocks was deteriorating and required further evaluation. R1 was transferred to the emergency room on 3/12/2020 and admitted to hospital. Upon admittance, the pressure injuries on R1’s left buttocks, left heel, and right heel, were all noted as unstageable. On 3/13/2020, the following pressure injuries were noted in R1’s hospital medical records: left ischial tuberosity deteriorated (ie. left buttocks), pressure injury, unstageable; right heel deteriorated … pressure injury, deep tissue pressure injury (DTPI); left heel deteriorated … pressure injury, deep tissue pressure injury (DTPI); right foot lateral no change, continued current treatment … pressure injury, deep tissue pressure injury (DTPI). R1 was not on hospice during this time. R1 was discharged from the hospital on 3/12/2020 and was sent to a skilled nursing facility. R1 was only at the facility from 3/4/2020 – 3/12/2020.

A review of medical records revealed that prior to R1 being admitted to this facility on 3/4/2020, R1 was in the hospital. Medical records indicated that R1 had a “left buttocks bruise” with an open sore and there was no indication that R1 exhibited any additional pressure sores at that time. An interview with R1 and the home health nurse whom cared for R1 confirmed that the additional pressure injuries noted on the heels developed during the short time at the facility. However, there was varied information as to whether staff would assist R1 with repositioning. Visit notes and home health interviews alleged that R1 would not allow facility staff to assist them with repositioning, did not ambulate to the restroom although they were capable of doing so, would urinate in their bed, and refused to reposition oneself. Home health interviews alleged that staff began putting diapers on R1, but home health believed that it made the pressure injury on R1’s buttocks worse. An interview with R1 revealed that they stayed in bed for most of the time, alleged that the staff failed to assist or rotate them, and R1 claimed they did ask for assistance, but staff did not change them often.

During the investigation, the Investigator attempted to collect documents pertaining to R1, but during the investigation, the facility changed ownership and the staff at the facility at that time had not worked with R1 and did not have knowledge pertaining to R1. An interview with the former property owner revealed limited information, as they too were unfamiliar with R1 and did not provide the contact information for former staff.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 29-AS-20200604144340

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: HERRIK HOME LLC	FACILITY NUMBER: 197609108
	VISIT DATE: 08/09/2021

NARRATIVE

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Yet there is sufficient evidence to support the claim that R1 developed multiple pressure injuries while in care. R1 was discharged to this facility on 3/4/2020 from the hospital, and R1 was noted to only have a ‘left buttocks bruise’ with an open sore and there was no indication that R1 had other pressure injuries. During the short time of being at the facility, R1 developed additional pressure injuries and they all were assessed as unstageable. Although R1 was non-compliant, would urinate in bed versus ambulating to the bathroom, would not reposition self and reportedly would not allow staff to reposition R1, and refused the visit from the home health nurse on 3/10/2020, the facility should had brought this behavior to the attention of R1’s physician in order to best meet R1’s needs. Whereas home health believes this facility took good care of R1 and noted that the facility had long-term residents who did not develop injuries, R1 developed multiple pressure injuries in the short stay at this facility. This allegation is deemed Substantiated at this time.

Regarding the allegation: Facility staff did not dispense medication as prescribed

It was alleged that R1 did not receive their medications while being at the facility. A review of home health notes documented that on 3/9/2020, it was noted that R1 had not had their medication for six days, indicating that R1 had not had their medication since being admitted on 3/4/2020. R1 was admitted to this facility on 3/4/2020 and a review of the discharge paperwork revealed that R1 was discharged to the facility with their medications. However, R1 did not receive their medications as needed. Notes documented that home health notified the Administrator that they needed to follow up with R1’s medications as soon as possible, with the Administrator alleged that they would. A nursing note on 3/10/2020 documented that R1’s medications were going to be picked up from the pharmacy late in the afternoon on 3/10/2020. Whereas there is insufficient evidence to confirm if R1 ever received their medications on 3/10/2020, there is sufficient evidence to support the claim that the facility staff did not dispense medication as prescribed, as the facility failed to obtain R1’s medication upon admittance to the facility on 3/4/2020 and it was discovered that R1 was without their medication for at least six days. This allegation is deemed Substantiated at this time.

Regarding the allegation: Facility staff did not ensure that resident’s blood sugar was monitored

It was alleged that the facility staff did not check R1’s blood sugar. Review of medical documents confirmed that on 3/4/2020, it was instructed for R1’s blood glucose supplies to be picked up at the pharmacy. Additional interviews and records review confirmed that R1 did not receive their medications and supplies from the pharmacy until 3/10/2020.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 29-AS-20200604144340

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: HERRIK HOME LLC	FACILITY NUMBER: 197609108
	VISIT DATE: 08/09/2021

NARRATIVE

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Based on the investigation, there is sufficient evidence to support the claim that the staff did not ensure that R1’s blood sugar was monitored, as the supplies were not picked up for an extended period of time. R1 was only at the facility from 3/4/2020 to 3/12/2020. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). An immediate civil penalty of $500 is also assessed for R1 developing multiple pressure injuries. A civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

A copy of this report was sent via certified mail.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 29-AS-20200604144340

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: HERRIK HOME LLC	FACILITY NUMBER: 197609108
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/09/2021 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(a)(1) Prohibited Health Condition. Persons who require health services for or have a health condition .. shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	This license was forfeited on 3/8/2021; hence no POC can be provided. The resident is no longer under the care of this licensee. An immediate $500 civil penalty was assessed.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as R1 was not on hospice nor was an exception submitted, yet R1 was retained at the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 08/09/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5) Incidental Medical and Dental Care. 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	This license was forfeited on 3/8/2021; hence no POC can be provided. The resident is no longer under the care of this licensee.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as R1 did not receive their medications from 3/4/2020-3/9/2020, nor was their blood sugar monitored as instructed, which poses an immediate health and safety risk to 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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
06/04/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200604144340

FACILITY NAME:	HERRIK HOME LLC		FACILITY NUMBER:	197609108
ADMINISTRATOR:	MELIKYAN, MARIA		FACILITY TYPE:	740
ADDRESS:	13303 REEDLEY ST		TELEPHONE:	(818) 644-1008
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	0	CENSUS: 0	DATE:	08/09/2021
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:			TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff did not safeguard residents money
Facility did not issue a refund
Facility staff cut resident's hair
Facility did not provide a good quality of food
Facility did not provide comfortable accommodations

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 29-AS-20200604144340

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: HERRIK HOME LLC	FACILITY NUMBER: 197609108
	VISIT DATE: 08/09/2021

NARRATIVE

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Regarding the allegation: Facility staff did not safeguard resident’s money
It was alleged that facility staff took money out of R1’s purse. The interview with R1 revealed that R1 felt that money was taken because they had stored the money in their tote under their pillow and alleged that the tote was missing from under their bed the following morning. R1 denied misplacing their tote bag thereafter and alleged that it was taken. During the investigation, the Investigator attempted to speak to staff, yet the facility changed ownership and the staff at that time had not worked with R1 and did not have knowledge pertaining to R1. The Investigator nor the LPA could obtain specific documentation pertaining to R1’s stay at the facility. Lastly, due to lack of documentation, the LPA was unable to identify documentation to confirm that the facility safeguarded R1’s items. Based on the information obtained, there is insufficient evidence to support the claim that staff did not safeguard resident’s money. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility did not issue a refund
It was alleged that as R1 was at the facility from 3/4/2020 – 3/12/2020, the facility should have issued a refund for the days not in the facility. However, during the investigation, the Investigator attempted to speak to staff, yet the facility changed ownership and the staff at that time had not cared for R1 and did not have knowledge pertaining to R1. The Investigator nor the LPA could obtain specific documentation pertaining to R1’s stay. Hence, the investigation did not allow for a review of a signed Admissions Agreement to identify if any pre-admission fees were paid. An interview with the former property owner revealed limited information, as they too were unfamiliar with R1 and did not provide the contact information for the former staff. Based on the information obtained, there is insufficient evidence to support the claim that given the circumstances, R1 was owed a refund for the days not in the facility. This allegation is deemed Unsubstantiated at this time

.Regarding the allegation: Facility staff cut residents hair
It was alleged that staff cut R1’s hair. Interviews with R1 revealed that they needed a haircut and alleged that upon mentioning it to staff, they proceeded to cut R1’s hair. R1 stated they did not like the haircut, but denied claims that they had asked staff to cut their hair. However, during the investigation, the Investigator attempted to speak to staff, yet the facility changed ownership and the staff at that time had not worked with R1 and did not have knowledge pertaining to R1. An interview with the former property owner revealed limited information, as they too were unfamiliar with R1 and did not provide the contact information for the former staff. Based on the information obtained, there is insufficient evidence to support the claim that facility staff cut R1’s hair. This allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 29-AS-20200604144340

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: HERRIK HOME LLC	FACILITY NUMBER: 197609108
	VISIT DATE: 08/09/2021

NARRATIVE

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Regarding the allegation: Facility did not provide a good quality of food
It was alleged that the facility food was not ‘diabetic friendly’. Interviews conducted with R1 revealed that whereas the facility had food, R1 did not find that it was good for ‘their diet’ and felt that they needed to buy food to supplement. After review of the facility file and previous visits while the facility was in operation, the LPA was unable to identify specific concerns voiced or observed regarding the quantity or quality of the food, nor was there concern discovered regarding the facility’s ability to address special diets. During the investigation, the Investigator attempted to speak to staff that worked in the home. The facility changed ownership and the staff at the facility at that time had not worked with R1 and did not have knowledge pertaining to R1. An interview with the former property owner revealed limited information, as they too were unfamiliar with R1 and did not provide the contact information for the former staff. Based on the investigation, there is insufficient evidence to support the claim that the facility did not provide a good quality of food. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff did not provide comfortable accommodations

It was alleged that the mattress provided for R1 was ‘thin’ and promoted R1’s skin breakdown. Interviews conducted and records reviewed confirmed that the cause of R1’s wounds were a result from lack of repositioning and from being in bed for an extended period of time. In addition, whereas R1 confirmed that the mattress was thin, there was insufficient evidence to confirm that R1 communicated their concern with the facility accommodations. Based on the investigation, there is insufficient evidence to support the claim that the facility staff did not provide comfortable accommodations. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. A copy of this report was sent via certified mail.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

Page: 8 of 8