197609766-3-22-2022-31-AS-EMIR-CCTUSG-20220324155019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609766
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:17:17 PM

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
03/21/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220321131259

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: 4	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Sona Gevorkyan		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff use postural supports to restrain residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit.
Upon entry LPA conducted a physical plant tour from 9:45-10am to ensure no immediate health and safety issues.
It is alleged that facility used postural supports inappropriately. It is alleged that staff use a gait belt on residents at night so they cannot move. LPA conducted interviews with residents from 10:45-11:30am. LPA conducted interviews with facility staff from 11:30-12pm regarding this allegation. LPA also reviewed resident files from 10:00-10:30am. Information revealed that resident #1 (R1) was prescribed a half bed rail but at night another half bed rail was put up in addition to the half bed rail R1 was already using. Based on the information obtained from record review and interviews this allegation is deemed Substantiated. Staff used half bed rail inappropriately. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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 4

Control Number 31-AS-20220321131259

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: 03/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/23/2022 Section Cited CCR 87608(a)(5)(B)	1 2 3 4 5 6 7	Postural support-Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit statement that all postural supports will be used as they are prescribed for. Statement will be sent to LPA.
	8 9 10 11 12 13 14	Based on interviews conducted facility used two half bed rails on R1's bed when they were sleep when only a half bed rail was noted to be used by physician which created a full bed rail. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
03/21/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220321131259

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:	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Sona Gevorkyan		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff do not meet training requirements.
Staff did not meet resident's incontinence needs.
Resident not given medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit.
Upon entry LPA conducted a physical plant tour from 10-10:20am to ensure no immediate health and safety issues.

It is alleged that facility staff do not have the proper training. LPA conducted interviews with residents from 10:30-11:30am. LPA conducted interviews with facility staff from 11:30-12pm regarding this allegation. LPA also reviewed staff records of S1 and S2 from 12-12:45pm. Based on interviews and record review it appears that facility staff do meet the training requirements. Therefore this allegation is deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20220321131259

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: 03/22/2022

NARRATIVE

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Staff did not meet resident's incontinence needs.
It is alleged that facility staff would not assist resident #1 (R1) as needed when they needed to use the restroom. LPA conducted an interview with R1's responsible person, residents, and facility staff regarding this allegation. LPA was not able to interview R1 as R1 has moved out of the facility. Information from interviews reveal there is not enough information to state that R1 was not assisted as needed when needing to use the restroom. Therefore this allegation is deemed Unsubstantiated at this time.

Resident not given medication as prescribed
It is alleged that R1 was not given their prn medication as prescribed. LPA interviewed R1's responsible person regarding this allegation. LPA interviewed facility staff from 11:30-12pm. LPA reviewed R1's medication documentation from 12:30-1pm. A review of R1's medication revealed that R1 was to be given Lorazepam(one tablet every four hours) as needed for agitations. Based on information obtained through interviews and record review there is not enough information to state that R1 was not given their medication as prescribed. Therefore this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

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