197609630-8-10-2022-31-AS-NMAN-CHKUCE-20220823152749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609630
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:52:36 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2021 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20210401133010

FACILITY NAME:	HEALTHY LIFE SERVICE FACILITY		FACILITY NUMBER:	197609630
ADMINISTRATOR:	TADEVOSYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	15921 LIGGET ST		TELEPHONE:	(747) 254-6056
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	0	CENSUS: 0	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Armine Dishoyan		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff failed to ensure that resident was adequately hydrated.
Resident missed his urologist appointment.
Staff failed to meet the resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced subsequent complaint visit on 8/10/2022 at 11:15am to deliver the investigative findings. Upon arrival LPA Lacy met with Administrator Armine Dishoyan and explained the purpose of this visit.

#1. Staff failed to ensure that resident was adequately hydrated

It is alleged that resident #1 (R1) was dehydrated. The above allegation was investigated by LPA Berry on 04/13/2021, interviews conducted with the administrator at 8:10am and R1s son the Power of Attorney (POA) at approximately 2:26pm. Interviews revealed R1s POA and family is very active in R1s care. Staff gave R1 water and R1 was able to tell staff when he wanted water, R1 also had a bell to call for staff. During the investigation R1s POA confirmed that R1 has nutrition issues because he refuses food or doesn't want to drink water and does not want to exercise. R1 is verbal, cognizant and is a strong-willed man.
Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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 31-AS-20210401133010

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197609630
	VISIT DATE: 08/10/2022

NARRATIVE

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He visits his father regularly and is in constant communication with facility staff. The POA confirmed he was informed by staff that his father does not do what he needs to do (eating, drinking, exercise) and his condition is worsening as a result. The POA has no concerns of neglect. Based on LPAs interviews and observation, Although the allegation may have happened or may be valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

#2. Resident missed his urologist appointment

It is alleged that on an unknown date the resident missed his urologist appointment. To investigate the above allegation interviews were conducted on 04/13/2021 with the administrator at 8:10am and R1s son the Power of Attorney (POA) at approximately 2:26pm, which confirm that R1s POA and family is actively involved in R1s care. Interview conducted with the Administrator by LPA Lacy on 05/27/2022 at 12:40pm confirmed that R1 missed their appointment when R1 was in the hospital and doesn’t recall if R1 missed any other appointments. Interviews with POA revealed that POA was responsible for making R1 urologist appointments and he has no concerns of neglect. Based on LPAs interviews and observation, although the allegation may have happened or may be valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

#3. Staff failed to meet the resident's needs

It is alleged that staff failed to meet R1 needs. To investigate the above allegation LPA Berry conducted interviews on 04/13/2021 with the administrator at 8:10am and R1s son the Power of Attorney (POA) at approximately 2:26pm. Administrator revealed that R1s POA and family are actively involved in R1s care, and there never express concerns of neglect in R1’s care. During the investigation R1s POA confirmed the information revealed from staff. POA stated that he visits his Parent regularly and is in constant communication with facility staff. Based on LPAs interviews and observation, Although the allegation may have happened or may be valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No heath and safety hazard are noted during this visit.
Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC9099 (FAS) - (06/04)

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