197609747-3-29-2022-29-AS-DPEA-CDQTTF-20220422150037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609747
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:35:19 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
03/16/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210316101604

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: 4	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Svetlala Petrosian -		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff caused injury to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation initiated by LPA on 03/17/2021. LPA met with Svetlala Petrosian and explained the reason for the visit. Adminstrator stated Svetlala can sign for the report in their absence.

On 03/16/2021, the Department received a complaint which alleged that staff caused injury to Resident #1 (R1). It was reported that R1 was injured during a physical altercation with the administrator.

On 03/17/2021, Licensing Program Analyst (LPA) Brian Balisi initiated a 10-day complaint visit conducted virtually due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). LPA met with Administrator Robert Mkrtchyan and explained the reason for the visit. The LPA conducted a tour of the physical plant and requested copies of census, staff schedule, admission agreement and pertinent documents relevant to the investigation to be sent to the LPA via email by the end of the day.

Unsubstantiated

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: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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 29-AS-20210316101604

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: 03/29/2022

NARRATIVE

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Continued from 9099

On 07/27/2021, LPA conducted a subsequent complaint investigation visit. A tour of the physical plant was conducted at approximately 2pm. Interview with staff was conducted approx. at 2:15pm. Interviews with residents and families were approximately between 2:45pm – 4pm. Additionally, at 2:45pm, LPA reviewed and obtained additional pertinent documentation. On 03/25/2022, LPA obtained and reviewed Los Angeles Police Department (LAPD) Incident Reports for facility address. Additional interviews were conducted on 03/28/2022, with R1’s representatives.

Information gathered revealed that there was an incident that occurred on 03/08/2021, R1 began yelling at Staff #2 (S2) as S2 was making their rounds for care. R1 began showing signs of aggression towards S2 and attempted to strike S2. S1 intervened and stepped between R1 and S2 in an attempt to redirect R1. R1 then grabbed S1's arms and kept their arms bent and close to S1’s chest. S1 sustained a scratch on S1's arm by R1 during this moment. S1 continued to stay between R1 and S2 until R1 became calm and was able to be redirected to their room. S1 then contacted the police as R1 appeared to be acting aggressive by yelling and pacing throughout the home. Police arrived shortly after the initial phone call and interviewed all the parties involved. All the parties involved, along with the family of R1, agreed to have R1 transported to the hospital. Per LAPD incident reports, no crime had occurred on this date. Per interviews conducted with R1’s family, R1 did not sustain any injuries from the incident and only staff was injured with a few cuts on S1 and S2’s arms. Further interviews conducted with residents in care revealed that none have witnessed any staff physically harm anyone in the facility at this time. LPA interview with staff revealed they have not witnessed any other staff physically harm anyone in the facility. Based on information gathered, the Department does not have enough evidence to confirm allegation listed above occurred. Therefore, the allegation “staff caused injury to resident” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

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