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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609640
Report Date: 08/20/2020
Date Signed: 08/20/2020 11:21:19 AM



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
08/19/2020 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200819123534
FACILITY NAME:MIRACLE ASSISTED LIVING FACILITYFACILITY NUMBER:
197609640
ADMINISTRATOR:GAYANE AGHABEKYANFACILITY TYPE:
740
ADDRESS:20648 LONDELIUS STTELEPHONE:
(747) 206-5390
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 6DATE:
08/20/2020
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rima AgaronyanTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
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9
Resident not able to communicate with family.
Staff not able to communicate with others.
INVESTIGATION FINDINGS:
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2
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5
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9
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12
13
Licensing Program Analyst (LPA) Wendell Smith initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Rima Agaronyan.

Resident not able to communicate with family
It is alleged that resident #1 (R1) is not being allowed to communicate with their family. LPA conducted interviews with R1, facility staff, and R1's family member. Information revealed that R1's family member did not have the correct telephone number for the facility. Also R1 was unaware that they had family that wanted to talk with them. Interview with facility staff revealed that they were not aware of any phone calls from R1's family and that the only family R1 had was their son (R2) who is a resident in the facility as well. Based upon the information obtained through interviews this allegation is deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
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 2
Control Number 31-AS-20200819123534
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: MIRACLE ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609640
VISIT DATE: 08/20/2020
NARRATIVE
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Staff not able to communicate with others.
It is alleged that one of the reasons that R1 was not receiving phone calls was that facility staff did not understand English and didn't understand how to put R1 on the phone. LPA conducted interviews with residents and facility staff. LPA also called the facility and was able to communicate effectively with facility staff who understood English. Based on the information obtained this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted and a copy of report will be emailed to administrator and sent back with signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2