197609747-9-25-2022-29-AS-JAPL-CJNLB8-20220927083618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609747
Report Date: 09/23/2022
Date Signed: 09/25/2022 01:57:54 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
09/16/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20220916155117

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: 6	DATE:	09/23/2022
		UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Rebeka Durgaryan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident received an unlawful eviction notice.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation above. The LPA was greeted by staff Svetlana Petrosian at 11:08 a.m. The staff contacted administrator Rebeka Durgaryan via telephone, and the administrator stated that she would come to the facility to meet with the LPA.

At 11:15 a.m., the LPA, and the staff conducted a brief tour of the facility. The LPA and the staff observed six (6) residents at the facility. There are three bedrooms with double occupancy in each bedroom. The LPA requested to see the file for R1, however the facility file for R1 was not available at the facility. Staff provided the LPA with R1's Hospice file. At 11:20 a.m., the LPA attempted to interview resident #1 (R1) in regards to the eviction notice, however R1's speech was unintelligible.

Continues on LIC 9099 C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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-20220916155117

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: 09/23/2022

NARRATIVE

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On 09/22/2022, the LPA interviewed the reporting party (RP) in regard to the allegation, and the RP stated that the R1's monthly fee for board and care was paid for two months (starting August 5th), and the next payment is due on October 5th.

At 1:06 p.m., the LPA interviewed the administrator Rebeka Durgaryan. The interview revealed that R1's monthly fee for board and care at the facility is paid until the end of the month of September 2022. Additionally, the administrator stated that they are in communication with R1's friend, who has paid the board and care fees, and that the R1's friend will continue to pay the monthly fee of $1,700 dollars. The administrator understands that in order to evict a resident for non-payment of monthly board and care fees, the administrator will have to issue an eviction notice to the resident, and inform the CCL department of the eviction notice.

No citations were issued. Exit interview conducted with administrator Rebeka Durgaryan. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC9099 (FAS) - (06/04)

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