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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609747
Report Date: 12/21/2021
Date Signed: 12/21/2021 01:57:40 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
05/04/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20210504161840
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:
12/21/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert MkrtchyanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care.
Facility retained a resident with a Stage 3 pressure injury
INVESTIGATION FINDINGS:
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On 12/21/2021, at 1:00 p.m., Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to issue the final report regarding an investigation into the allegations, ‘Resident sustained pressure injuries while in care’ and ‘Facility retained a resident with a Stage 3 pressure injury’. The LPA met with staff Robert Mkrtchyan, and explained the reason for the visit.

On 05/06/2021, at 8:05 a.m., Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena initiated a complaint investigation for the above allegations. The LPAs initially met with facility staff and spoke with Robert Mkrtchyan over the phone at 8:13 a.m. Mr. Mkrtchyan arrived shortly after.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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 7
Control Number 29-AS-20210504161840
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: 12/21/2021
NARRATIVE
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During the visit, the LPAs interviewed Robert Mkrtchyan from 8:26 a.m. to 8:50 a.m. The interview revealed that Resident #1 (R1) was admitted to the facility on 3/22/2021 with stage II pressure injuries; there were three (3) pressure injuries, one on the left heel, one on the right heel, and one on the coccyx area. Mr. Mkrtchyan stated that the pressure injury on the coccyx area was growing very rapidly, thus he recommended to send R1 to the hospital. Furthermore, the interview revealed that R1 was not receiving Home Health Care nor Hospice Care at facility, so there was not a physician’s order for care or an appropriately skilled professional caring for the pressure injuries.

On 05/06/2021, the Woodland Hills North Adult and Senior Care Regional Office referred this case to the Community Care Licensing (CCL) Investigations Branch (IB). On 05/07/2021, IB Investigator, R. Kujawa, Badge #54, was assigned to investigate the allegations.

Regarding the allegation, ‘Resident sustained pressure injuries while in care’, on 05/17/2021, Special Investigator Assistant (SIA), V. Padilla sent a subpoena to one hospital requesting the medical records for R1. On 05/27/2021, IB Investigator R. Kujawa, received a copy of R1’s medical records from the hospital. Additionally, on 09/15/2021, SIA V. Padilla sent a subpoena to a second hospital, requesting the medical records for R1. On 09/20/2021, IB Investigator R. Kujawa, received a copy of R1’s medical records from the second hospital.

The medical records review revealed that R1 was discharged from the hospital with skin tears on the right arm, which was treated with steri-stripes in place; the left arm had a skin tear, with recommendations to cleanse, and treat area daily. Discharge medical papers advised to contact the hospital, if wound care areas deteriorated, or if further evaluation was needed. R1 was discharged from the hospital, then admitted to Agnes Assisted Living on 3/22/2021.

On 07/15/2021, and 08/03/2021, IB Investigator, R. Kujawa interviewed facility staff. The interviews revealed that staff were aware that R1 had pressure injuries when R1 was admitted to the facility. Additionally, facility staff stated that R1 was not receiving home health care, hospice care, nor any special medical treatment, while R1 was residing at the facility. Treatment was being provided by facility staff, which consisted of changing bandages, and applying triple antibiotic cream to the pressure injuries, several times a day, and repositioning R1 every two hours.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20210504161840
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: 12/21/2021
NARRATIVE
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On 09/09/2021, IB Investigator, R. Kujawa interviewed the responsible persons for R1. The responsible person stated that R1 was admitted to Agnes Living Facility with stage 1 or 2 pressure injuries. The responsible persons were not aware of whether or not R1 was receiving home health care at the facility and stated that R1 was on a health decline when R1 was living at the facility. One responsible person stated that they were not planning to and did not arrange for home health care for R1.

When the IB investigator spoke with Mr. Mkrtchyan, the IB investigator was informed that it was Mr. Mkrtchyan’s understanding that the responsible person for R1 would be arranging for home health care services for the pressure injuries; however, the responsible person denied that was the case. As a result, although R1’s health may have been declining, it was the administrator’s responsibility to ensure that R1’s physician was notified of the pressure injuries and that R1 received the medical treatment needed. Mr. Mkrtchyan stated to the investigator that he has a history in the healthcare field and he personally was monitoring the pressure injuries but was not acting as the facility licensed vocational nurse (LVN). R1 was admitted to the facility on 3/22/2021 and did not receive any specialized wound care until R1 was hospitalized on 4/29/2021.

Based on the interviews conducted with facility staff and R1’s responsible parties; and, the medical records review, the investigation revealed that R1 was admitted to the facility with at least two (2) pressure injuries. It was determined that R1 was not provided with proper medical treatment for R1’s pressure injuries while in the care of Agnes Assisted Living facility. When R1 was admitted to the hospital, it was determined that R1 had pressure injuries on both buttocks, the left elbow, the left heel and bilateral shoulders. In addition, wound care was also required for R1’s penis. Therefore, the allegation that ‘Resident sustained pressure injuries’ while in care is deemed Substantiated at this time.


Regarding the allegation, ‘Facility retained a resident with a Stage 3 pressure injury’

On 05/06/2021, at 8:05 a.m., Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena initiated a complaint investigation for the above allegation. The LPAs initially met with facility staff and spoke with Mr. Robert Mkrtchyan over the phone at 8:13 a.m. Mr. Mkrtchyan arrived shortly after.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210504161840
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: 12/21/2021
NARRATIVE
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During the visit, the LPAs interviewed Mr. Mkrtchyan from 8:26 a.m. to 8:50 a.m. The interview revealed that Resident #1 (R1) was admitted to the facility on 3/22/2021 with stage II pressure injuries; there were three (3) pressure injuries, one on the left heel, one on the right heel, and one on the coccyx area. Mr. Mkrtchyan stated that the pressure injury on the coccyx area was growing very rapidly, thus he recommended to send R1 to the hospital for the pressure injuries. Furthermore, the interview revealed that R1 was not receiving Home Health Care nor Hospice Care at facility, so there was not an appropriately skilled professional caring for the pressure injuries.

On 05/06/2021, the Woodland Hills North Adult and Senior Care Regional Office referred this case to the Community Care Licensing (CCL) Investigations Branch (IB). On 05/07/2021, IB Investigator, R. Kujawa, Badge #54, was assigned to investigate the allegations.

Regarding the allegation, ‘Facility retained a resident with a Stage 3 pressure injury’, on 05/17/2021, Special Investigator Assistant (SIA), V. Padilla sent a subpoena to one hospital requesting the medical records for R1. On 05/27/2021, IB Investigator R. Kujawa, received a copy of R1’s medical records from the hospital. Additionally, on 09/15/2021, SIA V. Padilla sent a subpoena to a second hospital, requesting the medical records for R1. On 09/20/2021, IB Investigator R. Kujawa, received a copy of R1’s medical records from the second hospital.
The medical records review revealed that R1 was discharged from the hospital to the facility with skin tears on the right arm, which was treated with steri-stripes in place; the left arm had a skin tear, with recommendations to cleanse, and treat area daily. Discharge medical papers advised to contact the hospital, if wound care areas deteriorated, or if further evaluation was needed. R1 was discharged from the hospital, then admitted to Agnes Assisted Living on 3/22/2021.

On 07/15/2021, and 08/03/2021, IB Investigator, R. Kujawa interviewed facility staff. The interviews revealed that staff were aware that R1 had pressure injuries when R1 was admitted to the facility. Additionally, facility staff stated that R1 was not receiving home health care, hospice care, nor any special medical treatment, while R1 was residing at the facility. Treatment was being provided by facility staff, which consisted of changing bandages, and applying triple antibiotic cream to the pressure injuries, several times a day, and repositioning R1 every two hours.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20210504161840
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: 12/21/2021
NARRATIVE
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On 09/09/2021, IB Investigator, R. Kujawa interviewed the responsible persons for R1. The responsible person stated that R1 was admitted to Agnes Living Facility with stage 1 or 2 pressure injuries. The responsible persons were not aware of whether or not R1 was receiving home health care at the facility and stated that R1 was on a health decline when R1 was living at the facility. One responsible person stated that they were not planning to and did not arrange for home health care for R1.

When the IB investigator spoke with Mr. Mkrtchyan, the IB investigator was informed that it was Mr. Mkrtchyan’s understanding that the responsible person for R1 would be arranging for home health care services for the pressure injuries; however, the responsible person denied that was the case. As a result, although R1’s health may have been declining, it was the administrator’s responsibility to ensure that R1’s physician was notified of the pressure injuries and that R1 received the medical treatment needed. Mr. Mkrtchyan stated to the investigator that he has a history in the healthcare field and he personally was monitoring the pressure injuries but was not acting as the facility licensed vocational nurse (LVN). R1 was admitted to the facility on 3/22/2021 and did not receive any specialized wound care until R1 was hospitalized on 4/29/2021. By the time R1 was admitted to the hospital from the facility, the pressure injury on the coccyx developed into a stage 3 pressure injury. The LPA did not receive an exception request from the administrator to retain R1 in the facility with a stage 3 pressure injury.

Based on the interviews conducted with facility staff and R1’s responsible parties; and, the medical records review, the investigation revealed that R1 was admitted to the facility with some pressure injuries. It was determined that R1 was not provided with proper medical treatment for R1’s pressure injuries while in the care of Agnes Assisted Living facility, at which time at least one of several pressure injuries developed into a Stage 3 pressure injury. In addition, the administrator did not submit an exception request to retain R1 in the facility with a Stage 3 pressure injury. Therefore, the allegation that ‘Resident sustained pressure injuries’ while in care is deemed Substantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20210504161840
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: 12/21/2021
NARRATIVE
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The following deficiencies are observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. An immediate $500 civil penalty is being assessed today. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Citations were issued. Exit interview conducted. Today's reports, and appeal rights were reviewed with Administrator. Report was issued via email.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210504161840
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: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Condition (a) 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 is not met as evidenced by:
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Licensee agrees to provide training to staff on how to recognize the progression of pressure injuries, provide a plan of action on steps, which would include: frequent assessment by the administrator of the resident’s skin condition,
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Based on interviews and record reviews, the licensee did not comply with the section cited above, as R1 developed a stage 3 pressure injury and was retained at the facility with a stage 3 pressure injury, which poses an immediate health and safety risk to residents in care.
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staff trained to report any skin changes to the administrator, notifying the resident’s physician of the pressure injury, ensuring that treatment is provided by an appropriately skill professional, immediately seek a higher level of care if the Home Health nurse states that the wound has exceeded a stage 2 pressure injury.
Type A
01/07/2022
Section Cited
CCR
87631(a)(3)(A)
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87631 Healing Wounds-(a), the licensee shall be permitted to accept or retain a resident who...: (3) Residents with a stage one or two pressure injury must...diagnosed by a physician... (A) The resident shall receive care...from a physician or ...
This requirement is not met as evidence by:
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Licensee agrees to provide training to staff on how to recognize the progression of pressure injuries, provide a plan of action on steps, which would include: frequent assessment by the administrator of the resident’s skin condition,
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Based on interviews, and records review, the licensee did not comply with the section cited above, as R1’s pressure injuries were not care for by an appropriately skilled professional, which poses as immediate health and safety risk to residents in care.
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staff trained to report any skin changes to the administrator, notifying the resident’s physician of the pressure injury, ensuring that treatment is provided by an appropriately skill professional, immediately seek a higher level of care if the Home Health nurse states that the wound has exceeded a stage 2 pressure injury
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7