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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609640
Report Date: 03/14/2022
Date Signed: 03/14/2022 08:22:58 PM



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
11/16/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20211116143735
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:
03/14/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Rima Araronyan Administrator designee.TIME COMPLETED:
07:20 PM
ALLEGATION(S):
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Resident 1 (R1) developed multiple pressure injuries while in the licensees’ care.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff. Rima Araronyan Administrator designee arrived 6:05pm

Regarding the allegation listed above, it is being alleged that the R1 developed multiple pressure injuries while living at the facility. It is also being alleged that the pressure injuries worsened within weeks from last hospitalization. This investigation was conducted by Peter Zertuche, Investigator with Community Care Licensing Division’s Investigations Branch.

On 11/17/2021, LPA Yelena Avetisyan conducted an initial 10-day visit to initiate the investigation. On that day, at 9:30 am., LPA Avetisyan reviewed and obtained copies of facility records for resident #1 (R1) and other 6 residents. Additionally, at 8:27 am., the LPA initiated staff interviews. At approximately 9:15 am., the LPA toured the facility.

On 11/17/2021 and 11/18/2021, Investigator Zertuche subpoenaed Kaiser Medical and home health records for R1. Review of the records revealed the following: R1 was hospitalized on 11/1/2021.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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 4
Control Number 31-AS-20211116143735
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: 03/14/2022
NARRATIVE
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Hospital records noted R1 presented with 4 pressure injuries. On 11/4/2021 the hospital completed a referral for home health care. Hospital records also documented that facility was instructed to reposition R1 every 2 hours. On 11/5/2021 a Initial Evaluation/Assessment was completed by Infinite Home Health. Upon completion of the evaluation/assessment R1 was diagnosed with a stage 2 pressure ulcer of right ankle, and a stage 4 pressure ulcer rt lateral malleolus. Home health records document that after every visit the facility home health staff “reinforced frequent change of position and diaper.” Staff verbalized an understanding to the home health nurse.

R1 was again hospitalized on 11/13/2021 at which time R1’s pressure injuries were assessed and documented to have worsened and the following pressure injuries were noted: unstageable left heel, stage 4 right lateral malleolus and a healing Stage 2 right elbow.

On 12/2/2021 from approximately 1:30 to 2:30 pm Investigator Zertuche conducted interviews with the assistant administrator Rima Araronyan, facility staff and residents. When interviewed Ms. Araronyan denied knowledge of the pressure injuries being over stage 2. Additionally, Ms. Araronyan admitted that staff did not reposition the resident because he was refusing and was able to turn himself, however facility and medical records document that R1 has no movement on his right side at baseline and was bed bound. Staff did not document the refusal, did not notify R1’s physician or home health agency.

On 2/3/2022 LPA Avetisyan called Canyon Oaks Nursing and Rehabilitation and spoke with the Case Manager who confirmed that R1 did not have any pressure injuries when discharged from their facility.

Information obtained during the course of the investigation confirmed that R1 developed pressure injuries while living at the facility. On 11/5/2021 the right lateral malleolus pressure injury was diagnosed as a stage 4 which is a prohibited health condition. Licensee/administrator and staff failed to follow hospital/home health instructions to reposition R1 which resulted in the pressure injuries worsening therefore the allegation is Substantiated.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20211116143735
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2022
Section Cited
CCR
87615(a)(1)
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Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
This requirement was not met as evidenced by:
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Licensee, Administrators will schedule 4 hours vendorized training for themselves and all staff.

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Based on information obtained during the investigation the licensee did not comply with the cited section by retaining R1 at the facility with a stage 4 pressure injury which posed an immediate health and safety and personal rights risk to R1.
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1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 3/16/2022

2) Verification of completed training will need to be submitted to the LPA by 3/28/2022.
Type A
03/16/2022
Section Cited
CCR
87616(a)
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As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by:
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Licensee, Administrators and assistant administrators will schedule and attend 1 hours vendorized training related to the cited section..
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Based on information obtained during the investigation, the licensee did not comply with the cited section by not submitting an exception request to retain R1 at the facility with a prohibited health condition, which posed an immediate health and safety and personal rights risk to R1.
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1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 3/16/2022

2) Verification of completed training will need to be submitted to the LPA by 3/28/2022.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20211116143735
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2022
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement was not met as evidenced by: Based on the information obtained during the course of the investigation the licensee
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Licensee, Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section.

1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 3/16/2022
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failed to comply with the cited section by not following instructions provided by physician/skilled medical professional related to the care of R1 which resulted in R1 developing prohibited health conditions and posing an immediate health and safety and person rights risk to R1.
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2) Verification of completed training will need to be submitted to the LPA by 3/28/2022.

Because this violation resulted in resident developing prohibited health conditions as a result of improper care an immediate civil penalty in the amount of $500 is issued.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4