197609108-9-14-2022-31-AS-KHEN-CJBUAT-20220916152515

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609108
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:29:21 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
04/21/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 31-AS-20200421122355

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:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:			TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Failure to provide adequate care and supervision.
Failure to comply with reporting requirements.

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 allegations. At 2:00 p.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 04/29/2020 at 2:00 p.m., LPA Eva Miller interviewed the Designee for facility responsibility/ Administrator, Staff #1 (S1) Olena Lysenko and requested pertinent files and documents. Additionally, on 04/29/2020 LPA Miller interviewed Staff #2 (S2). On 05/08/2020, LPA Miller conducted a virtual subsequent complaint visit and conducted a physical plant tour. Between 05/08/2020 and 10/28/2020, LPA Lyndia Sager conducted interviews with two (2) staff, including the new owner of the facility. 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:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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 31-AS-20200421122355

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: 09/14/2022

NARRATIVE

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Regarding the allegations: Failure to provide adequate care and supervision.
On 04/21/2020, 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 leaving the facility on 04/18/2020 without the knowledge of staff on duty. While out of the facility R1 was injured and hospitalized. Interview conducted on 04/29/2020 with S2 revealed that on 04/18/2020, Staff #3 (S3) last checked on residents at 1:00 a.m. and reported that all resident appeared to be sleeping. According to the interview with S2, S3 did not hear anything or hear anyone leaving the facility. S2 stated that the facility received a call on 04/18/2020 at 3:00 a.m., from R1’s family member notifying the facility that R1 was hospitalized. The staff on duty was not aware that R1 had left the facility until they received the call. Additional interview conducted on 10/28/2020 with S2 revealed a different timeline of events from the initial interview conducted on 04/29/2020. On 09/07/2022, LPA Peraldi conducted a record review. The Incident Report regarding R1’s unauthorized absence and hospitalization described an unclear time frame from when R1 left the facility and when the facility was made aware of R1’s absence. The Incident Report stated that R1 left the facility through a bathroom window at 3:00 a.m. and that staff last checked on residents at 1:00 a.m. The Incident Report stated that the staff on duty, S3 did not observe R1 leaving the facility but made it unclear when S3 was made aware of the incident. The Incident Report also stated that the facility will have more night supervision moving forward. Additionally, on 09/07/2022, LPA Peraldi reviewed the facility’s Personnel Report (LIC 500) dated 04/01/2020. The Personnel Report showed a gap in night supervision on Tuesdays, Wednesdays, Fridays and Saturdays, as no staff was listed for night shifts. Furthermore, it was unclear which staff covers the night shifts on the above days. Based on the record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Regarding the allegations: Failure to comply with reporting requirements.
On 04/21/2020, the Department received a complaint in which it was alleged that the facility did not comply with reporting requirements. On 04/18/2020, Resident #1 (R1) left the facility without the knowledge of the staff and resulting in R1 being injured and hospitalized. It was alleged that the facility did not report the incident to R1’s responsible person. The facility is required to repot to licensing and to the person responsible for the resident within seven days of an incident. During the initial visit on 04/29/2020, LPA Miller requested pertinent files and documents from the facility which included a copy of the R1’s Incident Report. By the time the initial visit was conducted on 04/29/2020, Community Care Licensing (CCL) had not received the incident report regarding R1. Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200421122355

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: 09/14/2022

NARRATIVE

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The incident occurred on 04/18/2020 and the facility had seven days to submit a written incident report, which would have been 04/25/2020. The facility did not send or notify licensing of R1’s incident within the required time frame. Based on the record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 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.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20200421122355

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: 09/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/14/2022 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 poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 09/14/2022 Section Cited CCR 87211(a)	1 2 3 4 5 6 7	87211(a) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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 record review, the licensee did not comply with the section cited above, as the facility did not comply with reporting requirements regarding R1’s incident which poses a potential 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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

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