197609766-11-13-2023-31-AS-NMAN-D39RHQ-20240311130242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609766
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:45:31 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., 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 FACILITY		FACILITY NUMBER:	197609766
ADMINISTRATOR:	SONA GEVORKYAN		FACILITY TYPE:	740
ADDRESS:	9708 VALJEAN AVE		TELEPHONE:	(310) 720-4551
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	11/13/2023
		UNANNOUNCED	TIME BEGAN:	02:37 PM
MET WITH:	Sona Gevorkyan		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff gave resident unapproved dietary drinks

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility on 11/13/2023 to deliver findings.

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

A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023 and a subsequent visit on 10/31/2023.

Staff gave resident unapproved dietary drinks

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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-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: 11/13/2023

NARRATIVE

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(Cont from 9099C)

It was alleged that staff gave Resident #1 (R1) unapproved dietary drinks. Interview with Administrator revealed they offered R1 an Ensure drink one time but R1 refused the drink. Staff revealed that they keep resident hydrated at all times with water. Other witnesses interviewed during investigation revealed that they saw a “two-liter bottle” of water by R1.

Due to finding no evidence that the offered dietary drinks were ingested there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC9099 (FAS) - (06/04)

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