197609604-5-18-2022-29-AS-JAPL-CESVSW-20220526164214

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609604
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:23:36 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
05/12/2022 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20220512132643

FACILITY NAME:	HM SWEET HOME		FACILITY NUMBER:	197609604
ADMINISTRATOR:	NADRIAN, ASMIK		FACILITY TYPE:	740
ADDRESS:	6215 BLUEBELL AVENUE		TELEPHONE:	(818) 903-6302
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 4	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marine Arshakyan		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not inform authorized representative of resident's change of medical condition.

Resident #1 (R1) was placed on Hospice care without proper authorization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for an initial complaint inspection for the above allegation. The LPA met with Asmik Nadrian at 9:15 a.m., and explained the reason for the visit.

During today’s visit, the LPA conducted a physical plant tour with the Administrator at 9:35 a.m. From 9:15 a.m. until 9:35 a.m., the LPA conducted an interview with the administrator. From 1:20 p.m. until 2:30 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 2:30 p.m. until 3:00 p.m., the LPA conducted interviews with facility staff.

Continue on LIC 9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220512132643

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: HM SWEET HOME	FACILITY NUMBER: 197609604
	VISIT DATE: 05/18/2022

NARRATIVE

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Regarding the allegation, ‘Staff did not inform authorized representative of resident's change of medical condition,’ the complainant’s concern is that the facility staff did not inform Resident #1’s (R1’s) authorized representative that R1 was hospitalized due to altered mental status and respiratory distress.

During the investigation, LPA Walker conducted interviews with R1’s family member(s), administrator, and facility staff. Interview with R1’s family member(s) revealed that the facility did inform R1’s authorized representative of R1’s change of medical condition, and staff took the steps to ensure R1’s received immediate care. Interview with R1’s family member(s) also revealed that R1’s family was contacted upon observing R1’s altered mental status and respiratory distress. R1’s family member(s) stated that they went the facility, and agreed with staff to call 9-1-1. Interviews with the administrator, and facility staff revealed that staff notified R1’s authorized representatives, and provided medical assistance in a timely manner to address R1’s change in of medical condition.

Based on interviews which were conducted, facility staff did inform R1’s authorized representative of R1’s change of medical condition. Therefore, there is insufficient evidence to support the allegation ‘Staff did not inform authorized representative of resident's change of medical condition.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation, ‘Resident #1 (R1) was placed on Hospice care without proper authorization,’ the complainant’s concern is R1’s authorized representative did not approve hospice care for R1 and were not aware that R1 was on Hospice.

During the investigation, LPA Walker conducted interviews with R1’s family member(s), administrator, and conducted a record review. Interview with R1’s family member(s) revealed that the facility staff did tell R1’s family member(s) of R1 being placed on Hospice; and was explained the process of Hospice care, before signing any documentation. Interview with R1’s family members also revealed that the Hospice authorization formed were signed upon admission to the facility. Interviews with the administrator revealed that R1 was placed on Hospice by R1’s family with the assistance of R1’s placement agent.

Continue on LIC9099C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220512132643

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: HM SWEET HOME	FACILITY NUMBER: 197609604
	VISIT DATE: 05/18/2022

NARRATIVE

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Interview with the Administrator also revealed that R1's family member(s) told the Administrator that the Hospice ‘person’ talked to R1’s family, and R1’s family signed the paperwork to authorize R1 receiving Hospice. The administrator stated that R1 was admitted to the facility with Hospice. Record review revealed that R1’s authorized representative was informed, and authorized/ gave consent for R1 to receive Hospice services on the date R1 was admitted to the facility.

Based on interviews which were conducted and record review, R1 was placed on Hospice with proper authorization from R1’s family. Therefore, there is insufficient evidence to support the allegation ‘Resident #1 (R1) was placed on Hospice care without proper authorization.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

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