197609542-12-7-2021-29-AS-JAPL-CCMRRG-20220318131503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609542
Report Date: 12/07/2021
Date Signed: 12/07/2021 02:12:40 PM

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
10/12/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20211012112342

FACILITY NAME:	BLYTHE STREET ELDERLY CARE		FACILITY NUMBER:	197609542
ADMINISTRATOR:	OHANYAN, NONA		FACILITY TYPE:	740
ADDRESS:	13367 BLYTHE STREET		TELEPHONE:	(323) 947-7005
CITY:	N HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	5	CENSUS: 3	DATE:	12/07/2021
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Nona Ohanyan		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not manage resident incontinence.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent investigation visit for the above allegation. At 12:05 PM, the LPA was greeted by staff. Staff called administrator, as administrator was not present at the facility. Once Administrator Nona Ohanyan arrived at 12:20 p.m., the LPA explained the reason for the visit.

On 10/13/2021, LPA Salia Walker initiated an investigation visit at the facility. On this date, the LPA met with Administrator Nona Ohanyan, conducted a tour of the physical plant, and obtained copies of records pertinent to the investigation.

Continues on LIC 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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 2

Control Number 29-AS-20211012112342

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: BLYTHE STREET ELDERLY CARE	FACILITY NUMBER: 197609542
	VISIT DATE: 12/07/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At 12:10 p.m., the LPA, and the caregiver conducted a tour of the physical plant. At 12:30 p.m. the LPA conducted interviews with staff and residents. The residents interviewed stated that they wear pulls ups and some residents stated they wear regular underwear. Residents who wear pull-ups had an adequate amount of diaper packages in their closets. Residents stated that they don’t need assistance to change. LPA Urena interviewed the administrator about the schedule for changing soiled diapers. The Administrator stated that diapers are changed as needed, and are checked every two hours. LPA Urena interviewed staff about the schedule for changing soiled diapers. Staff explained that the current residents don’t need assistance, because they wear pull -up diapers, and residents are mobile to go to the bathroom on their own. Additionally, staff stated that residents are changed as needed and checked every two hours.

Based on the information gathered, and although one resident may have been left in a soiled diaper for an extended period of time, there were no other witnesses to the event, nor did any other resident experience that issue. Therefore, although the allegation may have happened or is valid, there is insufficient evidence to confirm that staff did not manage resident incontinence. Based on the interviews with staff, and residents and the information obtained and reviewed, the allegation is found to be Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted with administrator Nona Ohanyan. Signatures obtained. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2