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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609108
Report Date: 10/04/2021
Date Signed: 10/04/2021 07:51:10 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
02/02/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210202140632
FACILITY NAME:HERRIK HOME LLCFACILITY NUMBER:
197609108
ADMINISTRATOR:OLENA LYSENKOFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STTELEPHONE:
(747) 264-0032
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:0CENSUS: 0DATE:
10/04/2021
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:TIME COMPLETED:
08:00 AM
ALLEGATION(S):
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9
Failure to provide personnel sufficiently competent to provide necessary services & meet residents needs.
Failure of Administrator to be on premises a sufficient number of hours.
Failure to provide safe and healthful accommodations
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 02/10/2021, LPA Eva Miller conducted the initial virtual visit with Staff #1 (S1) from 1:30 p.m. to 2:30 p.m. for the purposes of interviewing S1, touring the facility, and requesting documents. LPA Miller also interviewed family member of a resident on 02/9/2021. LPA Smith, along with LPA Emily Peraldi conducted a visit to this location on 08/04/2021, which was relicensed as Golden Century Assisted Living Inc. (#195850126). The LPAs conducted a tour at 10:07 a.m., interviewed staff at 10:37 a.m., and 1:50 p.m., and interviewed residents at 11:33 a.m. and 11:38 a.m. LPA Peraldi interviewed a family member of a resident on 08/5/2021 at 1:52 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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 7
Control Number 29-AS-20210202140632
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: 10/04/2021
NARRATIVE
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Regarding the allegation: Failure to provide personnel sufficiently competent to provide necessary services & meet residents needs.
It was alleged that the staff was unfamiliar with the care needs of the residents. A review of the facility file revealed a change of ownership took place on 3/8/2021, yet the current staff at Golden Century Assisted Living Inc. (#195850126) also worked at this location when it was previously licensed as Herrik Home. Staff interviews revealed that staff were unable to detail which residents received hospice or home health services, and the current Administrator admitted that when they were present at the facility alone with the residents, they did not provide elements of care to residents, such as bathing, dressing, or feeding and expected other staff to administer care. A facility file review revealed that LPA Peraldi conducted a visit at this location on 09/17/2021 and during a records review, discovered that two (2) out of three (3) residents did not have current appraisals, one (1) out of two (2) residents did not have a current physician’s report on file and two (2) out of three (3) residents’ admission agreements were not current. During that visit, LPA Peraldi observed staff give a resident (R1) some cookies, yet, R1's physician report confirmed that the resident was on a pureed diet. These observed deficiencies were cited under the facility Golden Century Assisted Living Inc. (#195850126) on 09/17/2021. Based on the information obtained, there is sufficient evidence to support the claim that the facility failed to provide personnel sufficiently competent to provide necessary services & meet residents needs. This allegation is deemed Substantiated at this time.

Regarding the allegation: Failure of Administrator to be on premises a sufficient number of hours.
It was alleged that the facility did not have a current Administrator on the property for a sufficient number of hours. Staff interviews revealed that Staff #2 (S2) was said to have been the Administrator, but S2 claimed that they did not have their Administrator’s Certificate and had not been present in the facility a sufficient number of hours between January-February 2021. It was also confirmed that Staff #3 (S3) was the Administrator for some time, yet a facility file review revealed that S3 had communicated their resignation to the Department on 01/05/2021 and confirmed that they had resident 01/01/2021. LPA Miller spoke with S1 over the phone on 02/18/2021, whom confirmed that at that time, they were ‘interviewing’ for Administrators. Hence, the facility was without an Administrator for approximately 8 weeks. Interviews with staff and residents revealed that the consistent person on staff was Staff #4 (S4), yet S4 does not have an Administrator’s Certificate. Based on the information obtained, there is sufficient evidence to support the claim that the facility failed to have an Administrator on premises a sufficient number of hours. This allegation is deemed Substantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210202140632
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: 10/04/2021
NARRATIVE
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Regarding the allegation: Failure to provide safe and healthful accommodations
It was alleged that staff failed to wear masks while providing care and supervision to residents. A facility file review revealed that LPA Smith conducted in-person visits to this location on 07/20/2021 and 08/04/2021. During each visit, staff were without face coverings and only put on a mask when the LPA entered the facility. Other interviews with family members and residents confirmed that staff in this facility only put on masks when visitors come into the facility, and are regularly observed with masks on their chin or are without masks completely when providing resident care. Interviews with S1 revealed that S1 alleged that staff wore masks ‘unless they were ten feet apart’ and was otherwise unaware as to whether staff wore masks in the facility.

Based on the information obtained, there is sufficient evidence to support the claim that staff failed to provide safe and healthful accommodations, as staff failed to wear face coverings while providing care and supervision to residents in care, which is in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This allegation is deemed Substantiated at this time.

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.



A copy of this report was sent via certified mail to former licensee Arutyun Sayan.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20210202140632
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: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2021
Section Cited
CCR
87468.1(a)(2)
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3
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7
 87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents... shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is 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.
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9
10
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12
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14
Based on observation and interview, the licensee did not comply with the section cited above, as staff did not wear face coverings while providing care and supervision to residents in care, which poses an immediate health and safety risk to residents in care.

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Type A
10/04/2021
Section Cited
CCR
87405(a)
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87405(a) Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. The administrator... shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...
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This license was forfeited on 3/8/2021; hence no POC can be provided.
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This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above, as there was no designated Administrator for several weeks, which poses an immediate health and safety risk to residents in care.
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9
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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.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20210202140632
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: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2021
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs
This requirement is 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.
8
9
10
11
12
13
14
Based on interview and records review, the licensee did not comply with the section cited above, as staff were unaware of services to meet resident needs, which poses an immediate health and safety risk to residents in care.
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14
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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.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
02/02/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210202140632

FACILITY NAME:HERRIK HOME LLCFACILITY NUMBER:
197609108
ADMINISTRATOR:OLENA LYSENKOFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STTELEPHONE:
(747) 264-0032
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:0CENSUS: 0DATE:
10/04/2021
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:TIME COMPLETED:
08:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Failure to comply with residents rights to reasonable visits.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 02/10/2021, LPA Eva Miller conducted the initial virtual visit with Staff #1 (S1) from 1:30 p.m. to 2:30 p.m. for the purposes of interviewing S1, touring the facility, and requesting documents. LPA Miller also interviewed family member of a resident on 02/9/2021. LPA Smith, along with LPA Emily Peraldi conducted a visit to this location on 08/04/2021, which was relicensed as Golden Century Assisted Living Inc. (#195850126). The LPAs conducted a tour at 10:07 a.m., interviewed staff at 10:37 a.m., and 1:50 p.m., and interviewed residents at 11:33 a.m. and 11:38 a.m. LPA Peraldi interviewed a family member of a resident on 08/5/2021 at 1:52 p.m.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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 7
Control Number 29-AS-20210202140632
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: 10/04/2021
NARRATIVE
1
2
3
4
5
6
7
8
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11
12
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15
16
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32
Regarding the allegation: Failure to comply with residents rights to reasonable visits.
It was alleged that the staff weren’t making reasonable accommodations between family members and residents that resided at this location. Interviews with staff, residents, and responsible parties of residents whom reside at this location confirmed that when there were visitation restrictions due to COVID-19, families were asked to see the residents from outside the facility, meaning they would speak to the resident through a bedroom window. Otherwise, families communicated minimal concerns in having reasonable visits with the residents. Resident interviews revealed no difficulties in speaking to or seeing their family and had not experienced any limitations outside of local restrictions. Staff also claimed that they were able to accommodate virtual calls via FaceTime and communicated no issue in doing so if families requested it.

Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to comply with residents rights to reasonable visits. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. A copy of this report was sent via certified mail to former licensee Arutyun Sayan.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7