197609559-9-28-2023-29-AS-KHEN-CWVW53-20231023165827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609559
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:42:38 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/09/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20210809155552

FACILITY NAME:	ANO ONE FACILITY FOR THE ELDERLY		FACILITY NUMBER:	197609559
ADMINISTRATOR:	ATOYAN, ARTUR		FACILITY TYPE:	740
ADDRESS:	7907 STANSBURY		TELEPHONE:	(818) 616-2390
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Artur Atoyan, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to administer resident’s medication as prescribed.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent visit to deliver findings at this facility. At 1:30 p.m., the LPA met with Administrator and explained the reason for the visit.

During the initial visit on 08/17/2021, between 11:25 a.m. and 4:30 p.m., LPA Peraldi toured the facility, reviewed resident records and medications. During a subsequent visit, on 08/25/2021 between 9:30 a.m. to 5:00 p.m., LPA Peraldi and LPA Ashley Smith toured the facility, interviewed four (4) staff, including the Administrator, reviewed records and medications. During a subsequent visit on 05/19/2023 between 12:30 p.m. and 1:45 p.m., LPA Peraldi conducted a brief physical plant tout, conducted interviews with four (4) out of five (5) residents and with one (1) staff.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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 5

Control Number 29-AS-20210809155552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANO ONE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 197609559
	VISIT DATE: 09/28/2023

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

Regarding the allegations: Staff failed to administer resident’s medication as prescribed. It was alleged that staff failed to properly assist residents with the self-administration of medication as prescribed. During a subsequent visit, LPAs Peraldi and Smith conducted a review of medication and medication documentation with the Administrators and observed the following: Resident #2’s (R2’s) Carbidopa-Levodopa (sp) per directions from physician, was to be administered four (4) times a day. However, the Medication Administration Record (MAR) confirmed that the Administrators were assisting with the self-administration of this medication three (3) times a day. The Administrators explained that R2 would refuse one (1) tablet of the medication and would only take the medication three (3) times a day. Based on the observation and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, and California Health and Safety Code the following deficiency were cited (refer to LIC 9099-D). Failure to correct the deficiency may result in civil penalty.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/09/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20210809155552

FACILITY NAME:	ANO ONE FACILITY FOR THE ELDERLY		FACILITY NUMBER:	197609559
ADMINISTRATOR:	ATOYAN, ARTUR		FACILITY TYPE:	740
ADDRESS:	7907 STANSBURY		TELEPHONE:	(818) 616-2390
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Artur Atoyan, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect resulting in resident's poor hygiene.
Staff failed to assist residents with diabetes care.
Staff are not meeting residents’ incontinence needs.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent visit to deliver findings at this facility. At 1:30 p.m., the LPA met with Administrator and explained the reason for the visit.

During the initial visit on 08/17/2021, between 11:25 a.m. and 4:30 p.m., LPA Peraldi toured the facility, reviewed resident records and medications. During a subsequent visit, on 08/25/2021 between 9:30 a.m. to 5:00 p.m., LPA Peraldi and LPA Ashley Smith toured the facility, interviewed four (4) staff, including the Administrator, reviewed records and medications. During a subsequent visit on 05/19/2023 between 12:30 p.m. and 1:45 p.m., LPA Peraldi conducted a brief physical plant tout, conducted interviews with four (4) out of five (5) residents and with one (1) staff.

Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20210809155552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANO ONE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 197609559
	VISIT DATE: 09/28/2023

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

Regarding the allegations: Staff neglect resulting in resident's poor hygiene. Staff are not meeting residents’ incontinence needs. It was alleged that staff neglected Resident #1 (R1) hygiene and are not meeting R1’s incontinence needs. Interviews with staff revealed that residents, including R1 are bathed twice a week. Interviews with staff revealed that majority of residents wear diapers and that staff change resident’s diapers two (2) to three (3) times a day. Interview with Administrator revealed that R1 has a catheter and that R1 is on Home Health services. R1’s Home Health continues to monitor R1’s catheter and staff continue to tend to R1’s catheter within the scope of their care. During the physical plant tour on 8/17/2021, 08/25/2021 and 05/19/2023, residents appeared well groomed. The LPA’s did not smell any odors nor did residents indicate that staff are neglectful. Additionally, resident interviews did not reveal any issues with their incontinence needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff failed to assist residents with diabetes care. It was alleged that staff failed to assist residents with diabetes care. During the interview with the Administrator, it was revealed that two (2) out of five (5) residents, including R1 require assistance with diabetes care. The Administrator stated that staff supervise and assist the two residents with their diabetes care, including blood sugar check. The Administrator stated that the two residents can inject the insulin pen on their own. Interviews with residents did not reveal any issues with staff neglect towards diabetes care. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20210809155552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANO ONE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 197609559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/29/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 (a) (4) Incidental Medical and Dental Care...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Within 24 hours, the Licensee will notify LPA when training will be completed. Licensee agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL.
	8 9 10 11 12 13 14	Based on observation, record review, the licensee did not comply with the section cited above as R2’s medication of Carbidopa-Levodopa (sp) was not being assisted per directions from physician which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5