<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609766
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:09:20 PM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230629104943
FACILITY NAME:HORIZON ASSISTED LIVING FACILITYFACILITY NUMBER:
197609766
ADMINISTRATOR:SONA GEVORKYANFACILITY TYPE:
740
ADDRESS:9708 VALJEAN AVETELEPHONE:
(310) 720-4551
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
10/31/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Sona GevorkyanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
It was alleged that Resident sustained multiple ulcer wounds while in care
Staff did not seek timely medical care for resident.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 10:10 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was present at the facility.

A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023, at which time LPA Smith conducted a physical plant tour at approximately 11:20 am and conducted an interview with the administrator.

On 06/29/20223 this case was referred to the Community Care Licensing Investigations Branch (CCIB). Investigator Christine Ferris continued the investigation by conducting records review and interviews on 08/01/2023, 08/04/2023, and 08/30/23.

(Cont to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
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
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230629104943

FACILITY NAME:HORIZON ASSISTED LIVING FACILITYFACILITY NUMBER:
197609766
ADMINISTRATOR:SONA GEVORKYANFACILITY TYPE:
740
ADDRESS:9708 VALJEAN AVETELEPHONE:
(310) 720-4551
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
10/31/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Sona GevorkyanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident was hydrated
Staff did not observed a change in resident's condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 10:10 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was present at the facility.

A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023, at which time LPA Smith conducted a physical plant tour at approximately 11:20 am and conducted an interview with the administrator.

On 06/29/20223 this case was referred to the Community Care Licensing Investigations Branch (CCIB). Investigator Christine Ferris continued the investigation by conducting records review and interviews on 08/01/2023, 08/04/2023, and 08/30/23.

(Cont to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20230629104943
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HORIZON ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609766
VISIT DATE: 10/31/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont from 9099A)

Staff did not ensure resident was hydrated.

It was alleged that due to severe dehydration R1’s health condition got more complicated. Staff revealed that they keep resident hydrated at all times. Between 06/23/23 and 06/25/23 R1 was having swallowing difficulties but was able to intake fluids. Staff informed hospice services and staff also spoke to R1’s responsible party, who called 911.
A review of hospice records revealed that R1 ate and drank regularly. R1 was assessed for hydration during skilled nursing visits and there were no signs of dehydration. Other witnesses interviewed during investigation revealed that they saw a “two-liter bottle” of water by R1.

Due to finding no evidence to suggest fluids were withheld or any actions or lack thereof by staff contributed to R1s dehydration, there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time.

Staff did not observe a change in resident's condition

It was alleged that Staff did not observe a change in R1s condition. Interviews with staff on 06/30/23, 10/31/2023, and interviews conducted during the course of the investigation reveal that staff noticed R1’s wounds not healing. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety.

Based on interviews and records review staff monitored R1s condition and noticed changes in R1s condition consequently there is insufficient information to support the allegation. Therefore, the above stated allegation is determined to be unsubstantiated at this time.



Exit interview conducted/Appeals/Copy of report given.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 31-AS-20230629104943
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HORIZON ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609766
VISIT DATE: 10/31/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont from 9099)
It was alleged that Resident sustained multiple ulcer wounds while in care.

Staff interviews conducted on 08/01/2023, revealed that upon admission to the facility, staff assisting Resident #1 (R1) noticed a black bloody spot on R1’s coccyx. The spot felt hot like it was burning. Staff was repositioning and turning R1 every 2 hours. Interviews also revealed that although a “small, black spot” was noticed near R1’s coccyx, staff did not know “what was under the tissue,” but it was “deep when the skin opened on 06/13/2023”.



A review of hospice/palliative and wound care records conducted by the IB investigator revealed that while in care at the facility, R1 developed pressure injuries. As of 06/13/2023, the pressure injuries were staged as Stage 4. Although R1 was receiving wound care by medical professionals between 06/13/23 to 06/25/23, the conditions of the wounds got worse. Records revealed that a sacral stage 4 pressure injury was addressed and subsequently treated by the wound specialist. However, other Stage 4 pressure injuries noted in hospice records, were not addressed by medical professionals.

IB investigators review of the hospital records revealed,that on 06/27/2023, R1 was admitted to the hospital with multiple Stage 4 pressure injuries on sacrum, Stage 4 pressure injuries on the left and right buttock. R1 was diagnosed with sepsis (secondary to the buttock wound infection). In addition, R1 had several deep tissue pressure injuries. Overall, the investigation revealed that although facility staff including the Administrator had knowledge that R1’s pressure injuries were not healing, they failed to obtain all required information from the hospice agency and take appropriate measures to ensure that there is no immediate threat to the health and safety of the resident.

Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time.

Staff did not seek timely medical care for resident.

It was alleged that R1’s overall health condition was declining, and staff failed to provide emergency medical assistance on time. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing

(Cont to 9099C)

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 31-AS-20230629104943
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HORIZON ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609766
VISIT DATE: 10/31/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont from 9099C)
difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety. Staff admitted not contacting emergency services. Between 06/14/2023 and 06/27/2023 R1’s condition got worse. R1’s responsible party was contacted, and 911 was called by R1’s responsible party. A review of the medical records verified the information received from the staff.

Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time.



Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 31-AS-20230629104943
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HORIZON ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609766
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/02/2023
Section Cited
CCR
87615(a)(1)
1
2
3
4
5
6
7
Prohibited Health Conditions (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 was not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall submit a written plan describing how the facility shall prevent injuries to residents in care as a result of this deficiencies. Licensee shall submit to CCL no later than 11/02/2023
8
9
10
11
12
13
14
Based on record reviews & interviews, R1 wounds not healing, developed unstageable wounds while in care which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Request Denied
Type A
11/02/2023
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to do the following:
Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening and to ensure compliance to the cited regulation
Licensee shall submit to CCL no later than 11/02/2023

8
9
10
11
12
13
14
Based on the investigation, the licensee did not comply with the section cited, as staff did not seek medical attention for R1 in a timely manner, which posed an immediate health and safety risk to R1
8
9
10
11
12
13
14
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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7