197609604-12-20-2022-29-AS-JAPL-CMYUK4-20230111143826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609604
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:05:03 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
12/21/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211221131518

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: 6	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Asmik Nadrian and Mariam Baghdoyan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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1. Facility did not provide resident an adequate bed.
2. Facility staff did not provide resident movement outside of bed.
3. Residents beds had full rails.
4. Facility did not nutritiously and adequately feed resident.
5. Facility did not meet resident's hygiene needs.
6. Resident did not have a way of calling for help in an emergency.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with staff and explained the reason for the visit. Administrator Asmik Nadrian arrived shortly therafter, but was unable to stay for the duration of the visit.

During LPA Sandra Urena's initial visit on 12/23/2021, the LPA obtained documents and interviewed staff from 10:45 a.m. to 12:30 p.m. On 1/14/2022, LPA Salia Walker conducted a tour at 10:42 a.m., interviewed three staff from 10:30 a.m. – 11:15 a.m., and interviewed residents from 12:07 p.m. – 1:30 p.m. On 07/01/2022, LPA Walker, along with Long-Term Care Ombudsman (LTCO) representative, Kheanna Mosley conducted a visit, in which a tour was conducted at 9:15 a.m., documents were obtained, and interviewed three staff from 10:53 a.m. – 1:52 p.m. Hospice records were subpoenaed and reviewed. A representative from a hospice agency was interviewed on 12/20/2022 at 9:13 a.m. Today, the LPA toured the facility, interviewed staff at 11:20 a.m., 11:24 a.m., and 11:44 a.m., and interviewed residents at 12:05 p.m., 12:10 p.m., and 12:15 p.m. A file review was conducted at 12:40 p.m., and the LPA also observed lunch service provided to the residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 5

Control Number 29-AS-20211221131518

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: 12/20/2022

NARRATIVE

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Regarding the allegation: Facility did not provide resident an adequate bed.
It was alleged that the bed provided to R1 was inadequate. Interviews with staff and a hospice representative confirmed that the hospital bed was provided by the hospice agency, which was further confirmed by a review of the hospice order. Staff interviews confirmed that as needed, they would switch out R1’s mattress. Based on the information obtained through interviews and record review, there is insufficient evidence to support the claim that the facility failed to provide an adequate bed for R1, as the bed was provided by the hospice agency. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff did not provide resident movement outside of bed.
It was alleged that R1 was not moved from their bed. Resident interviews from 1/14/2022 revealed that two (2) out of five (5) residents mentioned they were moved from their bed once within that week. Residents interviews conducted on 12/20/2022 revealed that two (2) out of three (3) residents were assisted with being moved out of bed as needed. Staff also alleged that R1 was moved out of the bed ‘daily’ but also alleged that R1 did not like to move from their bed. An interview with staff and a hospice representative revealed that R1 experienced shortness of breath upon minimal exertion and mentioned that moving out of bed was sometimes challenging for R1. Staff noted that they assisted R1 with light exercises as instructed by hospice and would try to get R1 to move their extremities as often as possible. A review of hospice visiting notes indicated that upon visiting R1, R1 was observed out of bed and either sitting in a chair in their room or in the living room: 4/12/2020, 5/13/2020, 5/23/2020, 5/27/2020, 7/4/2020, 9/23/2020, 2/1/2021, 3/24/2021, 4/5/2021, 4/12/2021. However, this is not a complete indication of how often staff took R1 out of bed. Based on the information obtained, there is insufficient evidence to support the claim that the staff did not provide the resident movement outside of bed. Although the allegation may have happened, there is insufficient evidence to prove the claim at the time the complaint was received. The allegation is Unsubstantiated at this time.

Regarding the allegation: Residents beds had full rails.
It was alleged that R1 had full bed rails, and possibly without an order. Record review and interview revealed that R1 received the bed from the hospice agency. Although the hospice paperwork indicated that R1 had a hospital bed with half-rails, further records review confirmed that there was a separate signed order on file from R1’s physician for R1 to have a full bed-rail. Photo evidence and interviews confirmed that R1 had a full bed-rail on their bed. Based on the information obtained through interviews and record review, there is insufficient evidence to support the claim that R1’s bed had full rails without an appropriate order. This allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20211221131518

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: 12/20/2022

NARRATIVE

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Regarding the allegation: Facility did not nutritiously and adequately feed resident.
It was alleged that R1 was often served frozen food and was not adequately fed. During the visit conducted on 12/20/2022, the LPA observed that the facility had a sufficient supply of perishable and non-perishable food. The LPA observed lunch service, and identified that residents were served chicken, a salad, and grains. The LPA observed fresh fruit and vegetables and food was in good condition. The residents did not communicate any concerns regarding the food served. Staff said they regularly cook and prepare meals for the residents. Resident interviews revealed that in general, residents did not express concern when it came to the meals provided. Staff said residents received three meals a day, along with snacks. An interview with a hospice representative indicated that R1 was often observed with snacks at bedside and mentioned that staff would ask R1 about what they would like to eat. In addition, a review of hospice notes indicated that R1 had a low appetite and would consume between 30-50% of the meals provided. There was no indication that R1 did not consume meals due to the food options at the facility. Based on the information obtained, there is insufficient evidence to support the claim that the facility did not nutritiously and adequately feed the resident. Although the allegation may have happened or is valid, there is insufficient evidence to prove the at the time the complaint was received. The allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility did not meet resident's hygiene needs.
It was alleged that the facility failed to meet resident hygiene needs. An interview with a hospice representative revealed that upon seeing R1, R1 appeared well groomed and clean. This individual regularly saw R1 and mentioned that staff were ‘on top’ of R1’s care and denied claims that R1 ever appeared unkempt. In addition, it was communicated that staff kept R1’s skin dry and intact. As R1 was at risk for skin breakdown due to limited mobility and incontinence, the hospice representative confirmed that R1 did not sustain any pressure injuries while residing at this facility. A review of medical documents indicated that R1 received visits from a health aide that would care for R1’s grooming needs at least two times a week from 3/28/2020 – 11/24/2021. Notes indicated that the health aide would assist R1 with changing, bathing, washing and styling R1’s hair, teeth brushing, and nail care. Staff claimed that in between the health aide visits, they would assist R1 with hygiene care as needed. Residents supported claims that the staff assisted with hygiene needs, and residents appeared well groomed and clean. Based on the information obtained, there is insufficient evidence to support the claim that the facility did not meet the resident’s hygiene needs. Although the allegation may have happened or is valid, there is insufficient evidence to prove the claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20211221131518

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: 12/20/2022

NARRATIVE

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Regarding the allegation: Resident did not have a way of calling for help in an emergency.
It was alleged that R1 did not have a way of calling for help in an emergency. Interviews confirmed that R1 had a cell phone, which they often used. Staff claimed that they would assist R1 with charging their phone, and also explained that R1 could use the facility phone as needed. Staff also noted that R1 was observed using the phone on a regular basis. Information obtained from interviews with R1’s responsible parties supported claims that they would speak to R1 on the phone and that R1 would often post on social media sites. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that R1 had no way of calling for help in case of an emergency. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted with the Administrator over the phone. A copy of the report was issued. Staff were authorized to sign the report.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5