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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609633
Report Date: 10/26/2022
Date Signed: 10/26/2022 01:51:22 PM

Substantiated


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
11/30/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20211130152735
FACILITY NAME:ORCHID LIVING BOARD AND CARE INCFACILITY NUMBER:
197609633
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:16729 TULSA STREETTELEPHONE:
(747) 239-3219
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 5DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Anna Petrosyan - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not seek timely medical treatment for resident's injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegations. LPA met with Administrator Anna Petrosyan and explained the reason for the visit.

On 11/30/21, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Christine Ferris. On 12/03/21 at 9:48 AM, LPA Patrick Shanahan initiated the complaint visit. LPA Shanahan interviewed the administrator and obtained copies of the facility records relevant to the investigation.

During the course of the investigation, Investigator Ferris interviewed the administrator, staff, family member, Hospice staff and witness on different dates and time from 12/09/21 to 02/14/22. IB Investigator Ferris also reviewed hospice records on 01/03/22. (continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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 31-AS-20211130152735
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: ORCHID LIVING BOARD AND CARE INC
FACILITY NUMBER: 197609633
VISIT DATE: 10/26/2022
NARRATIVE
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(continued from LIC 9099)

Regarding the allegation that the Facility did not seek timely medical treatment for resident's injuries, it was alleged that Resident #1 (R1) had had self-inflicted bruises on the night of 08/04/22 and failed to call the hospice agency to look after the injuries. IB Investigator Ferris’ interview with staff on 12/30/21 revealed that R1 had a self-injurious behavioral episode and became aggressive toward the staff. Staff called the administrator on the night of 08/04/21 and in the morning of 08/05/21 informing the administrator that R1 was not in good condition and needed assistance, the administrator told the staff that another staff would come and assist her but nobody did until 1:00 PM on the next day, 08/05/21. Further interview also revealed that the staff did not call the hospice on the night of 08/04/21 despite the fact that R1 was unable to calm down. IB Investigator Ferris’ interview with the Administrator on 12/09/21 revealed that the administrator called Hospice in the morning of 08/05/21. IB Investigator Ferris’ interview with the Hospice Nurse on 02/14/22 revealed that there was no record of call regarding R1 on the night of 08/04/21 as there would have been a triage record if there was.

Based on the information gathered during the course of the investigation, there is sufficient information to support the allegation and therefore deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20211130152735
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: ORCHID LIVING BOARD AND CARE INC
FACILITY NUMBER: 197609633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2022
Section Cited
CCR
87465(g)
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4)
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The facility is closed effective 10/12/22 due to change of ownership. This facility is now Assure Home Inc., (197610253). Cleared during visit.
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This requirement is not met as evidenced by::

Based on IB Investigator record review and interview, the llicensee did not immediately call hospice agency even after the staff informed the administrator that R1 was not in good condition. This poses an immediate health risk to the resident in care.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/30/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20211130152735

FACILITY NAME:ORCHID LIVING BOARD AND CARE INCFACILITY NUMBER:
197609633
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:16729 TULSA STREETTELEPHONE:
(747) 239-3219
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 5DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Anna Petrosyan - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained multiple injuries while in care

Staff did not prevent a resident from self harm

Facility has inadequate record keeping
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegations. LPA met with Administrator Anna Petrosyan and explained the reason for the visit.

On 11/30/21, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Christine Ferris. On 12/03/21 at 9:48 AM, LPA Patrick Shanahan initiated the complaint visit. LPA Shanahan interviewed the administrator and obtained copies of the facility records relevant to the investigation.

During the course of the investigation, Investigator Ferris interviewed the administrator, staff, family member, Hospice staff and witness on different dates and time from 12/09/21 to 02/14/22. IB Investigator Ferris also reviewed hospice records on 01/03/22. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20211130152735
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: ORCHID LIVING BOARD AND CARE INC
FACILITY NUMBER: 197609633
VISIT DATE: 10/26/2022
NARRATIVE
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(continued from LIC 9099)

Regarding the allegation that the Facility did not prevent a resident from self harm, it was alleged that Resident #1 (R1) had had self inflicted bruises on the night of 08/04/22 and the staff failed to stop R1 of self harm. IB Investigator Ferris’ interview with the Hospice Nurse on 02/14/22 revealed that R1 had already had multiple injuries on R1’s body when admitted to the facility and it was R1’s self injurious and R1’s combative and aggressive episodes are kind or “normal” for a person who is declining rapidly, Hospice nurse added that R1 was a hard case and did not suspect any abuse or neglect on the part of the staff. IB Investigator Ferris’ interview with R1’s family member (FM) on 01/20/22 revealed that FM did not believe that the staff harmed R1 and no concerns for abuse and/or neglect in the facility. IB Investigator Ferrris’ interview with Staff #1 (S1) on 12/30/21 revealed that the S1 was on duty and taking care of R1 all night.

Regarding the allegation that resident sustained multiple injuries while in care, it was alleged that a credible witnessed observed R1 with multiple injuries while visiting the facility. IB Investigator Ferris’ interview with the Hospice Nurse on 02/14/22 revealed that R1 had already had multiple injuries on R1’s body when admitted to the facility and it was R1’s self injurious and R1’s combative and aggressive episodes are kind or “normal” for a person who is declining rapidly, Hospice nurse added that R1 was a hard case and did not suspect any abuse or neglect on the part of the staff. IB Investigator Ferris’ interview with R1’s family member (FM) on 01/20/22 revealed that FM did not believe that the staff harmed R1 and no concerns for abuse and/or neglect in the facility.

Regarding the allegation that the facility has inadequate record keeping, it was alleged that the facility had no record for staff training. LPA's four (4) former staff record review today at 10:25 AM to 12:00 PM revealed that all former staff had training record on file.

Based on the information gathered during the course of the investigation, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5