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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609651
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:08:09 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20210210152037
FACILITY NAME:VILLA CATHERINE SENIOR CARE FACILITYFACILITY NUMBER:
197609651
ADMINISTRATOR:LUSINE I. ABRAMYANFACILITY TYPE:
740
ADDRESS:7001 VAN NOORD AVETELEPHONE:
(818) 279-4309
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 3DATE:
08/26/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Harut Manukyan - Caregiver TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff are financially abusing resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit on this day to deliver the complaint investigation findings for the above listed allegation. At 9:00 a.m., the LPA met with Harut Manukyan , the facility caregiver. LPA spoke with Lusine over the phone and she stated Harut can sign in her place.
On 02/22/2021, between 12:38pm and 2:00pm, LPA Balisi conducted an initial 10-day virtual visit, at which time, copies of pertinent documents from Resident 1’s (R1) facility file was requested; and, a virtual tour of the physical plant was conducted. Based on the nature of the allegation, the complaint was referred to Community Care Licensing Department’s Audit Division and General Auditor, Lisa Ni conducted the investigation.
On 2/26/2021, Auditor Ni conducted interviews with Pacific Western Bank Rosemead Branch staff and family members of R1. Auditor Ni also obtained and reviewed R1’s facility documents, and Pacific Western Bank Rosemead Branch’s surveillance video footage from 2/9/2021 between 12:34:55pm to 13:12:27pm.
(continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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 29-AS-20210210152037
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: VILLA CATHERINE SENIOR CARE FACILITY
FACILITY NUMBER: 197609651
VISIT DATE: 08/26/2021
NARRATIVE
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It was reported, that since 02/1/2021, checks were made out to “CASH” in R1’s name, in the amounts of $6,400, $6,000, $4,000 and $2,020. It was also reported that Staff 1 (S1), accompanied R1 to the bank and identified themselves as R1’s Power of Attorney (POA).

Information gathered and reviewed during the course of the investigation revealed that in early February 2021, R1’s family members received a call from Pacific Western Bank Rosemead Branch informing R1’s family that there were several suspicious checks in R1’s name made out to cash and to other entities. There were (5) written checks totaling in the amount of $22,400:

$4,000 made out to S1
$6,250 made out to cash
$6,400 made out to cash
$3,550 made out to Golden Century
$2,200 made out to Silver Hospice Care Inc.

The auditor’s interview with Pacific Western Bank Rosemead Branch banking staff revealed they had known R1 for about one year and that the signature on the checks were not consistent in comparison with R1’s signature depicted on the bank signature card. The banking staff stated when R1 was living by themselves, the monthly expense payments were usually utility bills and insurance. Payments were normally in the range of $50 to $100. The banking staff further revealed that on 2/1/2021, after multiple attempts to contact R1 and noticing multiple red flags, R1’s account was frozen to ensure no checks were cleared. It was further revealed that on 02/08/2021, the Pacific Western Bank Rosemead Branch received a phone call from someone pretending to be R1. The branch staff knew it was not R1 because of the different type of voice. The branch staff also knew R1 was having memory loss and/or mental illness. The individual who called in seemed to be very coherent. Later, the branch staff found out that this individual was a worker from the facility where R1 was residing. This individual wanted to find out why R1’s checks were being returned and if the bank could provide the process for adding a POA (Power of Attorney) to R1’s accounts. The branch staff did not give information to this individual because the branch staff knew this individual was not R1. On the same day, S1 called Pacific Western Bank Glendale Branch asking for the same information. The Glendale Branch did not give the information either and referred S1 to the Pacific Western Bank Rosemead Branch

Continued on 9099-C

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20210210152037
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: VILLA CATHERINE SENIOR CARE FACILITY
FACILITY NUMBER: 197609651
VISIT DATE: 08/26/2021
NARRATIVE
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On 02/09/2021, S1 brought R1 to the Pacific Western Bank Rosemead Branch. The branch manager spoke with R1 first, away from S1, to have a private conversation. R1 seemed to be very confused. R1 said they were in a car accident a week prior, and then R1 said they were in jail. R1 wanted the branch manager’s help to get them out. R1 was calling Villa Catherine Senior Care Facility a jail. R1 did not know who S1 was, and why they were at the branch. R1 was unable to verify all the checks that were returned by bank. After speaking with R1, the branch manager spoke with S1. S1 informed the branch manager that S1 was a long-time friend of the facility and just wanted to get paid for the care that R1 has been receiving. S1 provided the branch manager with R1’s hospital documents and documents showing that R1 was assigned to Villa Catherine Senior Care Facility. In addition, S1 informed the branch manager that S1 had a Power of Attorney (POA) over R1. The branch manager asked if S1 could provide a copy of the POA documents by email. S1 replied yes. S1 also informed the branch manager that R1 has a family member who was a witness to the power of attorney. However, up to current, S1 never sent the branch a copy of the alleged POA documents.

The auditor’s review of the video surveillance on 2/9/2021, revealed an unknown individual and S1 brought R1 to the Pacific Western Bank Rosemead Branch bank. The branch staff had a private conversation with R1 first at 12:36:54pm. Then, the branch staff had another private conversation with S1 at around 13:12:27pm.

During the course of the auditor’s investigation, R1’s monthly bank statement, Pacific Western Bank Rosemead Branch surveillance cameras, R1’s family members statement and the bank manager’s statement were received and reviewed. It was determined that the licensee’s relative/friend, S1, stole R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account. Due to the unusual checks that were written and the unfamiliar signature, which did not match with the bank records, the bank froze R1’s account immediately. The forged checks were not cleared and there was no financial loss in R1’s bank account. However, based on information obtained through the Auditor’s investigation, the allegation that Facility staff are financially abusing resident is deemed SUBSTANTIATED at this time.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D).

Exit Interview conducted/ Citations issued/ Civil Penalties issued/ Appeal Rights Discussed / A Copy of Report Issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210210152037
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: VILLA CATHERINE SENIOR CARE FACILITY
FACILITY NUMBER: 197609651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited
HSC
1569.269(a)(10)
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Enumerated rights; severability(a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: To be free from neglect, financial exploitation... physical, or sexual abuse.

This requirement is not met as evidenced by:
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Licensee agreed to review enumerated rights and provide LPA a written statement on how they will prevent a repeat violation. Licensee will send statement to LPA via email by POC date.
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Based on Auditing department’s interviews and record review licensee did not comply as licensee’s friend/relative stole R1’s checkbook, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account, which poses an immediate health and personal rights risk to persons in care.
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Type B
08/31/2021
Section Cited
CCR
87405(3)
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87405(3) Administrator Qualifications and Duties – Ability to maintain or supervise the maintenance of financial and other records.

This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide documentation of scheduled training for Administrator and staff. Licensee will send documentation via email by POC date.
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Based on Auditors interviews and record review, the licensee’s relative/ friend was able to access R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account, which potential health and personal rights risk to persons 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4