197609108-9-14-2022-29-AS-KHEN-CJBV8V-20220916161321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609108
Report Date: 09/14/2022
Date Signed: 09/14/2022 05:36:04 PM

Unsubstantiated

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
08/11/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20200811100140

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:	04:51 PM
MET WITH:			TIME COMPLETED:	05:37 PM

ALLEGATION(S):

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Staff did not meet resident's care needs.

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 4:55 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 08/20/2020 at 9:13 a.m., LPA KaSandra Lopez interviewed the Designee for facility responsibility/ Administrator, Olena Lysenko and requested pertinent files and documents. On 08/25/2020, LPA Lopez conducted a virtual subsequent complaint visit and conducted a physical plant tour and interviewed the Administrator and Staff #1 (S1). 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.

Unsubstantiated

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)

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Control Number 29-AS-20200811100140

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: Staff did not meet resident's care needs.
On 08/11/2020, the Department received a complaint in which it was alleged that the facility staff did not meet all the resident’s care needs. Interview conducted on 08/20/2020, with the Administrator revealed that the facility would have two (2) caregivers working. The Administrator explained that they only go to the facility twice a week. On 09/07/2020, LPA Peraldi reviewed all available documents and interviews obtained during the two previous investigations. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted. A copy of the report 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)

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