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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609766
Report Date: 04/07/2022
Date Signed: 04/07/2022 06:07:47 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
03/26/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210326092829
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: 4DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Svetlana PetrosyanTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Licensee/administrator failed to provide appropriate level of care and supervision which resulted in R1 sustaining multiple pressure injuries.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff .Svetlana Petrosyan and Volunteer Anush Danelyan. Ms. Petrosyan contacted administrator Sona Gevorkyan via telephone. LPA spoke with Ms. Gevorkyan who stated she is far from facility and would not be able to come for the visit. Ms. Gevorkyan designated Ms. Petrosyan to sign for the report.

Regarding the allegation listed above, it is being alleged that the R1 was admitted to the hospital twice in less than one month. Upon the 03/23/2021 admission to the hospital, concerns of neglect were reported due to pressure injuries. This investigation was conducted by Douglas Real, Investigator with Community Care Licensing Division’s Investigations Branch (IB).

On 5/12/2021, Investigator Real conducted a review of Kaiser Permanente medical records. Additionally, on various days from 05/12/2021 to 06/24/2021 Investigator Real conducted interviews with facility residents, administrator, staff, and other relevant parties.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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-20210326092829
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: 04/07/2022
NARRATIVE
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The review of the records revealed the following: R1 was hospitalized on 03/23/2021. Upon admission, R1 was diagnosed with septic shock and acute organ dysfunction and diagnosed with unstageable pressure injury on coccyx, an unstageable pressure injury on left and right heels, deep tissue pressure injury on ischium, a stage III pressure injury (vs trauma) on the leg, deep tissue pressure injuries on the left and right hips, and a deep tissue pressure injury on the left lateral posterior back. Hospital records also documented that R1 was bed bound since sustaining a hip fracture 02/17/2021.

Interviews conducted by Investigator Real revealed the following: Administrator and staff were not aware of R1 having pressure injuries prior to hospitalization; however, when interviewed the administrator recalled seeing some “bedsores” on R1’s back. According to the administrator, the pressure injuries were initially open but improved over time and closed. Administrator did not provide approximate time the pressure injuries were observed, or documentation related to the care of the pressure injuries. Additionally, Staff 1 (S1) recalled seeing an injury on R1’s buttocks but did not recall if it was open or closed. R1 received home health services from 02/26/2021 to 03/08/2021 however the services did not include wound care. Home health care staff did not identify pressure injuries.

Information obtained during the course of the investigation revealed that R1 developed pressure injuries on or after 03/08/2021. R1 did not receive care for the pressure injuries from a physician or skilled medical professional until being hospitalized on 03/23/2021, therefore the allegation of neglect/lack of care and supervision is substantiated.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210326092829
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: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's RP
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Licensee/Administrator and all staff will attend vendorized training related to the cited sections.

1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022
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This requirement was not met as evidenced by: Based on IB investigation record review and interview, the licensee/administrator did not comply with the cited section by not having knowledge of R1’s pressure injuries prior to hospitalization which posed an immediate health and safety and personal rights risk to R1
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2) Verification of completed training will need to be submitted to the LPA by 4/19/2022.

Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to ensure compliance with cited regulation at all times.
Type A
04/08/2022
Section Cited
CCR
87631(a)(3)(A)
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the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:(3)Residents with a stage 1or2 pressure injury must have the condition diagnosed by a physician/appropriately skilled professional. (A)The resident shall receive care for the pressure injury from a physician/appropriately
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Licensee, Administrator will schedule 6 hours vendorized training for themselves and all staff related to the cited section as well as the following title 22 regulations. 87615, 87609, 87611, 87612, 87613.

1) Verification of the scheduled training with the credentials of the trainer will need to be
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skilled professional. This requirement was not met as evidenced by: Based on IB investigation record review & interview, the licensee/admin did not comply with the cited section by not having R1's pressure injuries diagnosed & treated by a physician/appropriately skilled prof. Which posed an immediate health and safety risk to R1
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emailed to the LPA by 4/9/2022
2) Verification of completed training will need to be submitted to the LPA by 4/19/2022.

Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to ensure compliance with cited regulation at all times.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20210326092829
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: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2022
Section Cited
CCR
87464(f)
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Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement was not met as evidenced by:
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Licensee, Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section.

1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022
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Based on IB investigation record review and interview, the licensee/administrator failed to provide proper care and supervision by not having knowledge of R1's various pressure injuries, which due to neglect were diagnosed as prohibited health conditions upon hospitalization posed an immediate health and safety and personal rights risk to R1
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2) Verification of completed training will need to be submitted to the LPA by 4/19/2022.

Because this violation resulted in resident developing prohibited health conditions as a result of improper care an immediate civil penalty in the amount of $500 is issued.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4