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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609356
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:00:33 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
04/07/2022 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20220407161129
FACILITY NAME:YMZ ASSISTED LIVINGFACILITY NUMBER:
197609356
ADMINISTRATOR:REBEKA DURGARYANFACILITY TYPE:
740
ADDRESS:6206 KLUMP AVENUETELEPHONE:
(818) 322-8838
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:0CENSUS: 0DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rebeka DurgaryanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident in care is being financially abused
Staff do not ensure residents are properly fed while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 04/14/2022 by LPA S. Walker and a subsequent visit was conducted on 01/19/2023 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Administrator, Rebeka Durgaryan. Entrance interview conducted.

During the initial visit on 04/14/2022, LPA S. Walker conducted a physical plant tour at 2:35 p.m., and briefly spoke with the administrator and obtained copies of documents pertinent to the investigation between 2:05 p.m. and 2:30 p.m. On 01/19/2023, LPA M. Arroyo conducted a plan tour at 11:42 a.m., conducted interviews with the administrator and two residents between 11:48 a.m. and 1:08 p.m., and began record review and obtained copies of pertinent documents relevant to the investigation at 12:15 p.m.

...Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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 29-AS-20220407161129
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: YMZ ASSISTED LIVING
FACILITY NUMBER: 197609356
VISIT DATE: 02/07/2023
NARRATIVE
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...Report Continued from LIC 9099...

It was alleged that resident in care is being financially abused. It was reported that the facility attempted to scam Resident #1 (R1). Additionally, the Administrator attempted to force R1 into signing a form assuming responsibility for all financial fees owed to the facility. Review of records revealed that R1’s Admissions Agreement dated 6/26/2021 states on page 3 under Payment Provisions that’s R1’s total monthly bill is $1,500 per month and is due no later than the 5th calendar day of each month. Upon R1’s admission to the facility, R1’s monthly bill was to be paid by a third-party company called Summit Payee Services, Inc. However, the company only paid for the first three months of R1’s rent. The administrator stated trying many times to get into contact with the company responsible for paying, but no one ever picked up. The following month, the administrator stated contacting R1’s family regarding R1’s monthly bill, but the family insisted that the company was still paying for R1. Later on, the administrator came to find out that same company had closed and taken the money of many clients that were receiving SSI. The administrator contacted R1’s case manager and they suggested the facility try and get the rent directly from R1’s SSI. Record review revealed the administrator had filled out; however, had not submitted the Medical Source Opinion of Patient’s Capability to Manage Benefits Form SSA-787(12-2018) UF and Request to be Selected as Payee Form SSA-11-BK(01-2014) EF (01-2014). The administrator reported not going through submitting the application because they did not feel comfortable doing so. Interviews conducted revealed the facility did not have an interest in obtaining R1’s monthly allowance from SSI but wanted to obtain the rent due that had not been paid. Furthermore, on Form SSA-11-BK, page 3, #10 it asks: Does the claimant owe you/your organization any money now or will he/she owe you money in the future? Administrator stated resident had not paid rent in four (4) months. $1,500 per month times 4 months resulting in $6,000 in back pay. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “resident in care is being financially abused” is deemed Unsubstantiated at this time.

...Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220407161129
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: YMZ ASSISTED LIVING
FACILITY NUMBER: 197609356
VISIT DATE: 02/07/2023
NARRATIVE
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...Report Continued from LIC 9099C...

It was also alleged that staff do not ensure residents are properly fed while in care. It was reported there was an occasion when R1 went to bed and had called their family member to say they were not giving them food. During the visit on 01/19/2023, the LPA observed the kitchen and food supply. The facility had a variety of food including fruits, vegetables, milk, meats, eggs, and bread. The facility has a total of three refrigerators, one in the kitchen and two in the garage. Interviews conducted revealed the staff cook at least three meals a day for all residents. Family members stated visiting the facility and observing staff cooking and bringing the meals to the residents and added that staff have also offered visitors food if they are visiting during mealtimes. Interviews with residents revealed staff make breakfast every morning and they never need to ask staff to bring any of the regular meals. Residents stated staff cook as often as they want and if they get hungry in between meals, the staff will ask what they would like to have. Furthermore, residents stated not recalling the last time they requested a meal because the staff continuously bring their meals without having to ask. Based on LPA observation and interviews, the Department does not have sufficient evidence to support the allegation of “staff do not ensure residents are properly fed while in care”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of this report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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, 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
04/07/2022 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20220407161129

FACILITY NAME:YMZ ASSISTED LIVINGFACILITY NUMBER:
197609356
ADMINISTRATOR:REBEKA DURGARYANFACILITY TYPE:
740
ADDRESS:6206 KLUMP AVENUETELEPHONE:
(818) 322-8838
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:0CENSUS: 0DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rebeka DurgaryanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident eloping from facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 04/14/2022 by LPA S. Walker and a subsequent visit was conducted on 01/19/2023 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Administrator, Rebeka Durgaryan. Entrance interview conducted.

During the initial visit on 04/14/2022, LPA S. Walker conducted a physical plant tour at 2:35 p.m., and briefly spoke with the administrator and obtained copies of documents pertinent to the investigation between 2:05 p.m. and 2:30 p.m. On 01/19/2023, LPA M. Arroyo conducted a plan tour at 11:42 a.m., conducted interviews with the administrator and two residents between 11:48 a.m. and 1:08 p.m., and began record review and obtained copies of pertinent documents relevant to the investigation at 12:15 p.m.

...Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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 29-AS-20220407161129
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: YMZ ASSISTED LIVING
FACILITY NUMBER: 197609356
VISIT DATE: 02/07/2023
NARRATIVE
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...Report Continued from LIC 9099A...

It was alleged that lack of supervision resulting in resident eloping from the facility. It was reported that the front gate was left open and R1 wandered out to the yard and was missing for three days. Interviews conducted with the administrator revealed that on 08/18/2021, R1 opened the front door and walked outside while one staff was cooking, and another was assisting another resident. A few minutes later, the staff went to get R1 to have lunch, but realized R1 was gone. The administrator reported calling the police department and filing a missing person report. It was not until several days later, the police department had found R1 wandering in the street and brought them back to the facility. Based on all information gathered during the course of the investigation, the above allegation, “lack of supervision resulting in resident eloping from facility” is deemed Substantiated at this time.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D).



Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of this report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220407161129
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: YMZ ASSISTED LIVING
FACILITY NUMBER: 197609356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2023
Section Cited
CCR
87464(f)(1)(C)
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Basic Services "Care and Supervision" means the facility assumes responsibility for…or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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No Plan of Correction as this Facility Closed Effective 07/08/2022
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Based on all information gathered, the licensee did not comply with the section cited above as R1 was left unattended which resulted in R1 eloping and walking out of the facility unassisted which poses an immediate health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6