197609747-7-27-2021-29-AS-DPEA-C993EZ-20211129171158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609747
Report Date: 07/27/2021
Date Signed: 07/27/2021 01:56:35 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
05/15/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20200515095753

FACILITY NAME:	AGNES ASSISTED LIVING		FACILITY NUMBER:	197609747
ADMINISTRATOR:	MELIKYAN, NARINE		FACILITY TYPE:	740
ADDRESS:	7846 AGNES AVE		TELEPHONE:	(323) 675-8888
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	07/27/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Robert Mkrtchyan - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit on this day to deliver complaint investigation findings for the above listed allegation. At 1:00pm, LPA met with Robert Mkrtchyan, the facility administrator.
On 05/19/2020 between 10:30am and 12:30pm, 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. Investigator Lorraine Patterson from Community Care Licensing Division’s Investigation’s Branch (IB) conducted the investigation. On 07/02/2020, 07/08/2020, 07/09/2020, and 07/16/2020, Investigator Patterson conducted interviews with facility staff and residents. Interviews were also conducted with other relevant parties, including but not limited to, R1, hospice nurses, Long-Term Care Ombudsman (LTCO), and the Los Angeles Police Department (LAPD) on 07/07/2020, 07/09/2020, 08/13/2020 and 08/18/2020. Investigator Patterson obtained and reviewed police report and video evidence between 07/08/2020 and 08/17/2020. Moreover, on 07/02/2020, Investigator Patterson attempted to interview R1 and was informed that R1 expired on 05/24/2020 due to circumstances unrelated to the incident.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200515095753

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: 07/27/2021

NARRATIVE

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Continued from 9099

It was reported that on 05/14/2020 at approximately 4:30pm, an unknown elderly resident was heard yelling and screaming, “don’t hit me,” and “don’t pull my hair.” Additionally, it was alleged that it was visible that an unknown staff was observed to be slapping the resident while feeding the individual.

Information gathered and reviewed during the course of the investigation revealed R1 occupied the room where the screams were heard. Moreover, per interviews facility administrator positively identified Staff #1 (S1) as the staff in the video evidence. Video evidence reviewed revealed that at 00:00:03, R1 begins to scream and yell. At 00:00:14, S1 can be seen quickly raising S1’s left arm and hand. S1’s left hand appears to be up and open before S1 brings S1’s arm and hand down swiftly in a rough manner. As S1 brings S1’s arm and hand down, a skin to skin slap is heard. R1 continues to yell out again. At 00:00:30, R1 is heard yelling out. S1 is seen raising S1’s left arm and hand for a second time. S1’s left hand appears to be up and open before S1 brings S1’s arm and hand down in a swift and rough manner. A second skin to skin slap is heard. R1 appears to be stunned as an indicated by a brief pause and followed by more yelling out. Between 00:00:30-00:00:56, R1 continues to yell out. At 00:00:56, S1 appears to lean in close to R1’s bed where R1 is lying and attempting to sooth R1. Between 00:01:06 and 00:04:27, R1 appears to be calm while S1 remains at R1’s bedside. Furthermore, during the course of the investigation, S1 provided inconsistent statements relating to the incident. Based on information obtained through IB investigation the allegation “facility staff handled resident in a rough manner” is deemed SUBSTANTIATED at this time.

The licensee was informed that a civil penalty might be assessed based on Health and Code 1569.49(f).

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

Exit Interview conducted/ Citations issued/ Appeal Rights Discussed / A Copy of Report Issued via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200515095753

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: 07/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/28/2021 Section Cited CCR 87413(a)(2)	1 2 3 4 5 6 7	87413 (a)(2) Personnel – Operations – Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee has since terminated S1. Licensee also agreed to review section 87413(a)(2), train staff on regulation and provide LPA with a detailed written statement on how they will prevent a repeat violation. Licensee will send statement to LPA via email by end of business on POC date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the above section by failing to protect a resident from physical abuse by a staff member, which is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

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