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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609342
Report Date: 03/25/2021
Date Signed: 04/01/2021 11:06:29 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2019 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190826155619
FACILITY NAME:LOS FELIZ GARDENSFACILITY NUMBER:
197609342
ADMINISTRATOR:SHAPIRO, NONNAFACILITY TYPE:
740
ADDRESS:205 E LOS FELIZ ROADTELEPHONE:
(818) 241-2273
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: DATE:
03/25/2021
UNANNOUNCEDTIME BEGAN:
05:12 PM
MET WITH:Lesine HakobyanTIME COMPLETED:
05:13 PM
ALLEGATION(S):
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Lack of supervision resulting in inappropriate interactions between resident's.
Staff failed to contact 911 on behalf of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Lesine Hakobyan.

The investigation consisted of the following: LPA requested a copy of the staff roster, resident roster, to review all (SIRs)special incident reports for February 2019 and March 2019 and requested copies. LPA interviewed the Administrator Nonna Shapiro and Administrator Lesine Hakobyan and requested copies of specific documents for resident #1 and resident #2. LPA Attempted to interview resident #1 and resident #2 and was not successful.

Investigation revealed the following: Regarding allegation Lack of supervision resulting in inappropriate interactions between resident's. LPA Wesley reviewed the staff roster, observed staff working in the facility and interviewed Administrator Nonna Shapiro who advised that the facility is adequately staffed in addition there are
continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
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 6
Control Number 28-AS-20190826155619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342
VISIT DATE: 03/25/2021
NARRATIVE
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two nurses and two med techs during each shift. Administrator Shapiro indicated that there was no inappropriate interactions observed to take place with between resident #1 and resident #2. Administrator Shapiro advised that she interview resident #2 about the allegations and they denied entering into resident #2's room without their permission, trying to touch them inappropriately and laying in resident #1's bed in a sexual position(want to know what laying in a sexual position was). Resident #2 was very upset that they were questioned about this and also said: "why would they want to do something like that with a person that age?" Administrator Sharpiro also denied ever saying that staff saw resident #2 enter into the resident #1 room. Administrator also asked #2 asking if they ever took money from resident #1 to go purchase items from the store for her. Resident #2 denied the allegation as was very agitated that someone would make those things up about them. Administrator Lesine Hakobyan interviewed Resident #1 to confirm the allegations and resident #1 replied "NO! Was that a dream? I don't remember saying that!" Administrator Hakobyan also asked if they had ever given resident #2 money to purchase store items for them, and resident #2 replied "no" and said it was a staff, and when resident #1 was asked the name of the staff, they said : "a staff who no longer works in the facility." Resident #1 also denied that they screamed and the staff came to assist to quiet them down when they saw a naked man in their room. Administrator Hakobyan indicated that resident #1 has a history of hallucinating. Administrator Shapiro indicated that doctors came to the facility to examine resident #1 and had to adjust their medication 2 times that week(02/26/19). Administrator Hakobyan said that resident #2 has resided in the facility for about 10 years and they never experienced them to behave in appropriately and said they are so nice as a person and does not act in an inappropriate manner. Administrator Hakobyan also indicated that one time resident #1 asked for her to go to their room because their daughter, son-in-law and their kids(resident #1's grand children)were in there and said: "Can you please go get them out!" Administrator said they went to the room and there was no one inside resident #1's room. LPA Wesley attempted to interview resident #1 and learned that they expired on 06/11/2019, prior to the department receiving the complaint which was filed on 08/26/2019. LPA Wesley made attempts to interview resident #2 and they were not present in the facility on 09/04/19 and 08/03/20. The investigation revealed that there in not sufficient evidence to support the allegation.

Regarding allegation: Staff failed to contact 911 on behalf of resident. During the interview with Administrator Shapiro she advised that in the past resident #1 was always calling 911, and when the Glendale police arrived, the observed there was no emergency situation, and as resident #1 continued to call 911, the Glendale police got angry and informed the facility not to call 911 for non emergency reasons. Administrator Shapiro said does (Continued on LIC 9099C(page 3).
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20190826155619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342
VISIT DATE: 03/25/2021
NARRATIVE
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not recall resident #1 asking her to call 911, but she did call the Ombudsman(LTCO) for resident #1 on 02/27/19 as they stated they wanted some assistance dealing with a matter. LPA Wesley attempted to interview resident #1 and learned that they expired on 06/11/2019, prior to the department receiving the complaint which was filed on 08/26/2019. The investigation revealed that there in not sufficient evidence to support the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

There are no deficiencies cited. A telephonic exit interview was conducted with Administrator Lesine Hakobyan, and a hard copy was provided via email to obtain signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2019 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190826155619

FACILITY NAME:LOS FELIZ GARDENSFACILITY NUMBER:
197609342
ADMINISTRATOR:SHAPIRO, NONNAFACILITY TYPE:
740
ADDRESS:205 E LOS FELIZ ROADTELEPHONE:
(818) 241-2273
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: DATE:
03/25/2021
UNANNOUNCEDTIME BEGAN:
05:12 PM
MET WITH:Lesine HakobyanTIME COMPLETED:
05:13 PM
ALLEGATION(S):
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Staff failed to report an incident to licensing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Lesine Hakobyan.

The investigation consisted of the following: LPA requested a copy of the staff roster, resident roster, to review all (SIRs)special incident reports for February 2019 and March 2019 and requested copies. LPA interviewed the Administrator Nonna Shapiro and Administrator Lesine Hakobyan and requested copies of specific documents for resident #1 and resident #2. LPA Attempted to interview resident #1 and resident #2 but was not successful.

Investigation revealed the following: Regarding allegation: Staff failed to report an incident to licensing. LPA Wesley reviewed the facilities unusual incident reports for February 2019 and March 2019. During the interview with the Administrator Shapiro LPA Wesley inquired about the incident that occurred on 02/26/19 involving
Continued on LIC 9099AC.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20190826155619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342
VISIT DATE: 03/25/2021
NARRATIVE
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resident #1 and requested to review the incident report. Administrator Shapiro indicated that when she conducted an investigation and interviewed resident #1 several times the resident denied that the allegations occurred and because the facility could not prove the allegation they did not feel she had to report the incident. on 02/27/19, 03/07/19, and 04/25/19 the Administrator was advised by another agency that due to the type of allegation that was filed, "Lack of supervision resulting in inappropriate interactions between resident's," the Administrator is mandated to report the incident and cross report to all the appropriate agencies as well complete an unusual/special incident report according to title 22 regulations.

Based on Observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Administrator Lesine Hakobyan, and a hard copy was provided via email to obtain signature. Appeal rights were also included in the email.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 28-AS-20190826155619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2021
Section Cited
CCR
87211(a)(1)
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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event;
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Administrator Nonna Shapiro will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how she will ensure that incidents are reported to the CCL office as required according to the Regulation. Administrator must also conduct an inservice training to
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attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on observations and interviews: it was discovered that on 02/26/19, facility Administrator failed to report the incident involving resident #1 to CCLD and complete a SOC 341.
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staff in reference to Reporting Requirements and provide a copy of names and signatures of staff in attendance of training. POC is due to CCLD by 04/15/21
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6