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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609747
Report Date: 07/01/2021
Date Signed: 07/01/2021 03:53:01 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
06/17/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200617113333
FACILITY NAME:AGNES ASSISTED LIVINGFACILITY NUMBER:
197609747
ADMINISTRATOR:MELIKYAN, NARINEFACILITY TYPE:
740
ADDRESS:7846 AGNES AVETELEPHONE:
(323) 675-8888
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Robert MkrtchyanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff left resident in soiled diapers for extended periods of time

Staff are not giving resident sufficient assistance
INVESTIGATION FINDINGS:
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 At 9:08am on 07/01/2021, Licensing Program Analysts (LPA) Diaz, arrived at the facility to conduct an investigation to the allegations to this complaint. LPA met with Licensee, Robert Mkrtchyan and announced the reason for the visit was multiple complaint allegations.

On the allegation: Staff left resident in soiled diapers for extended periods of time. LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 6/11/21 at 3:54pm and on 6/14/21 at 2:52pm. LPA interviewed staff on 6/16/21 at 4:45pm and on 6/16/21 at 5:46pm. LPA interviewed residents on 06/16/21 at 3:23pm, 3:46pm and 3:52pm. LPA interviewed staff on 6/23/21 at 3:40pm. All staff consistently stated that Resident 1 (R1) wore pullups and was helped using the bathroom and being changed. All staff stated that R1 was alert and vocal when needing assistance from any caregiver in the facility. All residents in the facility wear pullups or a diaper. R1 and all residents are checked on every two hours or more, depending on the residents needs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 5
Control Number 29-AS-20200617113333
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: AGNES ASSISTED LIVING
FACILITY NUMBER: 197609747
VISIT DATE: 07/01/2021
NARRATIVE
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R1’s pull ups are checked twice a day to prevent rashes and incase R1 is leaking bodily fluids. All staff stated that R1 was never left unattended in a soiled diaper and R1 would tell staff if they were not dry or uncomfortable. All staff stated no residents have been left sitting in soiled diaper and staff would report any negligent incidences to the licensee. All residents interviewed stated the staff help residents use the bathroom and help residents change. According to the residents, they are frequently changed and there are no problems being changed. Based on the evidence gathered through interviews, the allegation is deemed unsubstantiated at this time.

On the allegation: Staff are not giving residents sufficient assistance. All staff consistently stated they provide sufficient care, and the facility has enough staff to provide care to the residents. The staff assist residents using the bathroom, changing, and with hygiene. Residents are comfortable with the caregivers and request help when they need it. When residents ring their bell, the caregivers immediately respond. The caregivers are constantly monitoring and communicating with all residents to ensure they are doing well. All staff document changes and report incidences to their supervisor that involve the residents. R1 was helped using the bathroom and being changed. All residents stated that they like living in the facility, caregivers provide everyone with assistance, and there are no problems. Resident 2 (R2) stated that the caregivers do not neglect R2. If the staff did not provide care to the residents, then R2 would not stay in the facility. Based on the evidence gathered through interviews, the allegation is deemed unsubstantiated at this time.

Exit interview, report given via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200617113333

FACILITY NAME:AGNES ASSISTED LIVINGFACILITY NUMBER:
197609747
ADMINISTRATOR:MELIKYAN, NARINEFACILITY TYPE:
740
ADDRESS:7846 AGNES AVETELEPHONE:
(323) 675-8888
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Robert MkrtchyanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff mismanaged resident's medications
INVESTIGATION FINDINGS:
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 At 9:08am on 07/01/2021, Licensing Program Analysts (LPA) Diaz, arrived at the facility to conduct an investigation to the allegations to this complaint. LPA met with Licensee, Robert Mkrtchyan and announced the reason for the visit was multiple complaint allegations.

On the allegation: Staff mismanaged resident's medications. All staff stated that they follow the MAR to administer medication. S1 stated that the facility began using the MAR about 1.5 months ago. Before using the MAR the facility used an internal notebook to log the administered medications. The internal log showed prescribed medications, start/cancelation dates of medications, when medications were administered, and the dosage administered. The internal log also indicated vitals, appetite and behavior. S1 is unsure if the facility maintains records of internal logs from last year.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200617113333
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: AGNES ASSISTED LIVING
FACILITY NUMBER: 197609747
VISIT DATE: 07/01/2021
NARRATIVE
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According to Licensee, the facility was administering medication to R1 but did not have MARs for R1. The Licensee was informed by R1 and R1’s girlfriend that R1 was leaving the facility to go home. R1s girlfriend told the licensee to give R1s personal belongings and medication to R1s driver. R1s driver requested the centrally stored medication and the physician report from the licensee. The License gave the driver R1s personal belongings, R1s medication, R1s centrally stored medication form and R1s physician report. The Licensee stated that they did not make a copy of the centrally stored medication form. On 07/01/2021 at 9:08am, Licensing Program Analysts (LPA) Diaz, arrived at the facility to examine the centrally stored medication and medications. LPA reviewed the centrally stored medication for resident 2 (R2). The facility did not have Risperidone, the medication illustrated on R2s centrally stored medication document. The Licensee also stated that they only have R2s centrally stored medication form for the month of June 2021 and no documents for prior months. At 10:38am LPA reviewed the centrally stored medication, and the medications for resident 3 (R3). LPA found 18 extra tablets of Carbidopa and found 2 extra tablets of Entacapone. LPA reviewed R3s MAR and there is no documentation of the resident refusing medication. All residents interviewed stated the staff always brings their medication. Based on the evidence gathered through interviews, observation and records reviewed the allegation is deemed substantiated at this time.

Exit interview, report given via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20200617113333
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: AGNES ASSISTED LIVING
FACILITY NUMBER: 197609747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2021
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced By:
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Licensee agreed to submit a plan to licensing about their new medication procedures. Plan will be submitted by 07/06/2021 to LPA by email (arien.diaz@dss.ca.gov)
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Based on medication review, the licensee failed to ensure medications were not given as prescribed for 2 out of 2 residents (R2, R3), which poses an immediate health and safety risk to residents 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5