197609747-4-5-2022-31-AS-DPEA-CDHP32-20220415105648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609747
Report Date: 04/05/2022
Date Signed: 04/05/2022 06:34:41 PM

Unsubstantiated

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
03/11/2020 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 31-AS-20200311140313

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:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Svetlana Petrosian		TIME COMPLETED:	01:51 PM

ALLEGATION(S):

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Staff pushed resident while in care.
Uncleared adult(s) working in facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted a subsequent complaint visit to deliver final finding for the above allegations. The initial visit was conducted on 03/20/2020 by former LPA Kristin Heffernan. During today’s visit, LPA met with and introduced self to staff Svetlanan Petrosian. Staff contacted licensee Robert Mkrtchyan and reason for visit as explained.

On 03/11/2020, the Department received a complaint alleging that “Staff pushed resident while in care” and that there are “uncleared adult(s) working in facility”.

On 03/202020, between 3:10 p.m. - 4:45 p.m., former LPA Heffernan conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually via facetime with Licensee - Robert Mkrtchyan, the licensee of the facility. Allegations were discussed with licensee and copy of documents pertinent to the investigation were requested. Following is a summary of the investigation:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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 31-AS-20200311140313

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: 04/05/2022

NARRATIVE

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Interview was conducted with reporting party and licensee on 3/20/2020; interview with Resident #1 (R1) on 12/10/2020 and 3/29/2022; interview with facility staff on 12/1/2020, 12/3/2020 and 12/10/2020; interview with facility residents conducted on 12/2/202 and 12/4/2020; other witnesses were interviewed on 11/06/2020, 12/1/2020 and 3/28/2022. In addition to the interviews, local Police Department was contacted however there was no police report filed for alleged incident(s).

Regarding allegation Staff pushed resident while in care – Two out of four residents interviewed (R1 and R2) reported that the licensee/administrator was aggressive at times however other staff are nice. Other two residents (R3 and R4) interviewed reported no issues or concerns with staff or licensee/administrator Robert Mkrtchyan. Residents interviewed reported feeling safe in the facility and stated that they have not witnessed any inappropriate behavior by staff or licensee/administrator Robert Mkrtchyan. Other potential witnesses interviewed denied seeing any resident being mistreatment by facility staff. Staff and licensee/administrator denied allegation and reported that they have not witnessed any facility staff mistreat any resident. R1 and R2 provided inconsistent statements and did not recall specific details to any alleged physical aggression made by licensee/administrator Robert Mkrtchyan. Interviews and records reviewed indicated that R1 and R2 have a history of aggression towards facility staff, and noncompliance issues with the administrator. Contact was made with local Law Enforcement and there were no police reports made/filed, but multiple call records.

Regarding allegation “Uncleared adult(s) working in facility.” – It was reported that the owner hires undocumented workers/uncleared adults to work at this facility. Individuals observed in the home during initial and subsequent visits made were fingerprint cleared and associated to the facility. Copy of the facility LIC500 Personnel Summary was obtained and reviewed. Staff listed on the LIC500 were confirmed to be cleared and associated to the facility. No additional details or supporting information provided by reporting party.

Based on the above, there is not enough evidence to support allegations. Therefore, allegations are deemed unsubstantiated at this time.

Exit interview conducted and of report provided by email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

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