<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609542
Report Date: 12/28/2022
Date Signed: 12/29/2022 08:11:30 AM

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
08/26/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220826155207
FACILITY NAME:BLYTHE STREET ELDERLY CAREFACILITY NUMBER:
197609542
ADMINISTRATOR:OHANYAN, NONAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(323) 947-7005
CITY:N HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:5CENSUS: 3DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nona OhanyanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident threatened with eviction while in care.
Adult sleeps in the common areas of the facility.
Staff are not providing adequate care and supervision to the residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to investigate the allegations mentioned above. The LPA arrived at the facility at 10:00 a.m., met with the Licensee Nona Ohanyan, and explained the reason for the visit.

On 09/01/2022, at 3:35 p.m., the LPA and the licensee conducted a brief tour of the facility. No deficiencies were noted during the tour. From 3:45 p.m. to 4:10 p.m., the LPA interviewed the licensee, and one resident out of three residents. From 3:40 p.m. to 3:45 p.m, the LPA conducted record review. On 08/31/2022, LPA Urena interviewed the Reporting Party (RP) from 1:37 p.m. to 2:14 p.m.

Continues on LIC 9099C...




Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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 2
Control Number 29-AS-20220826155207
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: 12/28/2022
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
On the allegation that the ‘resident was threatened with eviction while in care’, the Reporting Party’s (PR)concern was that Resident #1(R1) was asked to move out of the facility. LPA Urena interviewed the RP and collateral parties to investigate the allegation. The RP was interviewed on 08/31/2022 from 1:45 p.m. to 2:14 p.m. The interview revealed that RP’s place of employment assisted R1 with financial assistance through the local hospital which paid for R1’s board and care at Blythe Street Elderly Care Assisted Living. On 09/06/2022, record review revealed that there were two invoices paid for the board and care for R1. The first invoice covered for a time period of 60 days, beginning on 03/17/2022 and ending on 05/16/2022. The second invoice covered for a period 30 days, beginning on 5/17/2022 and ending on 06/17/2022. The licensee worked with the placement agency to apply for additional financial assistance for R1, but R1 did not qualify for the additional assistance. After the payments for the board and care stopped, the R1 remained residing at the facility until 08/29/2022, when the R1 left to be admitted at the hospital. Although the allegation may have happened, there is insufficient evidence to support the allegation that the resident was threatened. Therefore, this allegation is deemed Unsubstantiated at this time.

On the allegation that “Adult sleeps in the common areas of the facility’, the RP reported that an adult slept in the common area of the facility. The LPA interviewed the collateral parties on 12/27/2022 from 2:37 p.m. to 3:21 p.m. about this allegation. Per the collateral parties, the adult slept on the couch of the living room area for a few days, while the licensee was away from the facility. Although this may have happened, there is no additional evidence to support the allegation that the adult slept in the common areas of the facility. LPA interviewed the licensee about the allegation and licensee denied anyone sleeping on the couch. Therefore, this allegation is deemed Unsubstantiated at this time.

On the allegation that ‘Staff are not providing adequate care and supervision to the residents in care’, the RP’s concern is that staff at the facility were not fully tending to patient's needs, and they feel it is not safe for the residents who require additional care. The LPA interviewed the RP and the collateral parties, and they stated that there is not enough staff to care for the residents residing in the facility. On 08/31/2022, LPA Urena found that licensee was present as one of the caregivers and no other staff was present. During today's visit two caregivers were present for three residents. The record review of the facility’s staff roster revealed that one caregiver provides care from 9:00 a.m. to 5:00 p.m. and the evening caregiver is present from 5:00 pm. to 9:00 a.m. Based of the information obtained, there is sufficient staff to provide adequate care and supervision to residents in care. Therefore, this allegation is deemed Unsubstantiated at this time.

No citation were issued. Exit interview was conducted with the licensee. Copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2