197609108-9-12-2022-29-AS-KHEN-CJAQQD-20220915122211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609108
Report Date: 09/12/2022
Date Signed: 09/12/2022 12:35:53 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
04/30/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20200430164020

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:	09/12/2022
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:			TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Failure to provide adequate care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent telephonic complaint visit for the purpose to deliver findings for the above allegation. At 11:57 a.m., LPA Peraldi attempted to call Licensee, Arutyun Sayan and left a voicemail.

During the initial visit, conducted virtually to implement mitigation measures related the Coronavirus Disease 2019 (COVID-19) on 05/08/2020 at 2:00 p.m., LPA Eva Miller interviewed the Designee for facility responsibility/ Administrator Olena Lysenko and requested pertinent files and documents. Additionally, on 05/08/2020 LPA Miller interviewed a family member of a resident. Between 05/08/2020 and 10/28/2020, LPA Lyndia Sager conducted interviews with three (3) staff, including the Administrator at the time and three (3) witnesses. During the subsequent visit on 07/14/2022, LPA Peraldi conducted a visit to this location, which was relicensed as Golden Century Assisted Living Inc. (#195850126). LPA Peraldi conducted a physical plant tour and attempted to review records. Between 12:24 p.m. and 2:20 p.m., LPA Peraldi conducted interviews with one (1) staff, the current Licensee and one (1) resident.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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-20200430164020

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: 09/12/2022

NARRATIVE

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Regarding the allegation: Failure to provide adequate care and supervision.
On 04/30/2020, the Department received a complaint in which it was alleged that the facility did not provide adequate care and supervision to Resident #1 (R1) which resulted in R1’s neglect in oral hygiene, as well as sustaining bruises of unknown origin. Interview conducted on 05/08/2020 with R1’s family member revealed that shortly before being admitted to Herrik Home LLC, R1 had an incident at R1’s family members house of R1 climbing and falling out of a tree. Interview with R1’s family member revealed that R1’s family member did not believe that the facility staff at Herrik Home LLC neglected or abused R1. Interview also revealed that R1’s family member told the facility Administrator that R1 could perform activities of daily living such as oral hygiene and bathing, but not well enough. The Administrator ensured R1’s family member that facility staff will assist with R1’s oral hygiene and bathing. R1’s family member was not sure if the facility staff was properly brushing R1’s teeth since R1’s family member only visited R1 once after R1 was admitted to the facility. Interview conducted on 10/28/2020 with a Witness from the hospital that R1 was admitted to revealed that R1’s teeth were in a very bad and poor condition and the Witness stated that R1’s teeth had not been brushed for weeks. Interview conducted on 10/28/2020 with the Administrator at the time revealed that staff did not brush R1’s teeth and the Administrator reiterated that they never observed facility staff brushing R1’s teeth. The Administrator also stated that R1 had bad teeth and that R1 needed assistance with hygiene and bathing.

On 09/06/2022, LPA Peraldi conducted a record review of R1’s documents, including Appraisal/Needs and Service Plan and Preplacement Appraisal Information. The record review revealed that R1 was admitted to Herrik Home with bruises throughout R1’s body due to R1’s previous incident that occurrent at R1’s family members house. R1’s Preplacement Appraisal Information stated that R1 was very independent and refused assistance with activities of daily living such as hygiene care from facility staff. It was also noted that R1’s showering will be supervised for R1’s safety. Additionally, it was checked off that R1 did not need assistance with bathing, hair care and personal hygiene. However, R1’s Physicians Report was not sent to LPAs; R1’s Physicians Report, Admission Agreement and Incident Report from R1’s 04/29/2020 hospitalization was requested by LPA Miller on 05/08/2020 and by LPA Sager on 10/27/2020. On 07/14/2022, LPA Peraldi attempted to conduct a record review at this location but did not locate R1’s files. Furthermore, LPA Peraldi was not able to cross reference R1’s Preplacement Appraisal Information and R1’s Needs and Service Plan with R1’s Physicians Report. Continued on LIC 9099-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20200430164020

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: 09/12/2022

NARRATIVE

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Without R1’s Physicians Report/ medical assessment, LPA Peraldi could not confirm that R1 did not need assistance with activities of daily living such as bathing, grooming and oral hygiene. The facility is required to obtain and keep on file a resident’s medical assessment signed by a physician. Additionally, interview with the Administrator at the time on 10/28/2020, revealed that the facility files were unorganized and that the facility staff did not leave shift notes and did not complete incident reports. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D).

Exit interview conducted. Appeal rights provided. A copy of the report and appeal rights was issued to the former Licensee via mail for signature.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20200430164020

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: 09/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/12/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f) (1) Basic Services (f) 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 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 record review, the licensee did not comply with the section cited above, as the facility did not provide R1 with adequate care and supervision which led to R1 having neglected oral hygiene, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

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