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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609766
Report Date: 06/25/2022
Date Signed: 06/25/2022 06:54:57 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
04/28/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200428160827
FACILITY NAME:HORIZON ASSISTED LIVING FACILITYFACILITY NUMBER:
197609766
ADMINISTRATOR:SONA GEVORKYANFACILITY TYPE:
740
ADDRESS:9708 VALJEAN AVETELEPHONE:
(818) 300-8393
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
06/25/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Sona GevorkyanTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Neglect Lak of Care and Supervision. Resident 1 (R1) developed multiple Unstageable Pressure Injuries while in care.
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 Rosa Tonoyan, who contacted administrator Sona Gevorkyan via telephone. Approximately 1:00 pm Ms. Gevorkyan arrived to the facility.

Upon arrival LPA conducted a brief tour of the facility and spoke with Staff. While conducting the tour LPA observed the 2 backyard gates exiting the facility pad locked. 1 of the 2 gates is not used as an exit.

Regarding the allegation listed above, concerns of Neglect/Lack of Care resulting in Resident 1 (R1) developing multiple pressure injuries while living at the facility were reported. This investigation was conducted by Olivia Spindola, Investigator with Community Care Licensing Division’s Investigations Branch (IB) and Licensing Program Analyst (LPA) Yelena Avetisyan.

Continued on 9099 (c)

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: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
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-20200428160827
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: 06/25/2022
NARRATIVE
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On various days from 05/14/2020 to 07/08/2020 Investigator Spindola conducted interviews with facility residents, staff, administrator and other relevant parties. Additionally, on 5/28/2020 and 6/15/2020 Investigator Spindola conducted review of Medical Records from All Saints Hospice subpoenaed on 5/14/2020 and Northridge Hospital subpoenaed on 5/12/2020.

On 3/16/2022 LPA Y. Avetisyan requested Discharge Records for R1 from Casitas Care Center. The records were received on 3/23/2022.

On 4/11/2022 LPA Avetisyan issued a second subpoena to All Saints Hospice to obtain complete hospice records for R1. . Records were received on 4/12/2022, 4/14/2022, 4/21/2022. Due the agency not submitting all records as requested in the subpoena LPA requested records to be prepared for pick up along with custodian of records documentation. The records were picked up on 5/22/2022 however Custodian of records confirmation was not provided. From 4/14/2022 to 4/25/2022 LPA conducted various email communication with All Saints Hospice Agency staff to clarify information documented in the records.

When interviewed on 5/14/2020 and 6/15/2020 the Administrator stated that R1 was admitted to the facility on 02/20/2020 and hospitalized on 4/23/2020 due to trouble breathing. Per administrator R1 was living at the facility with hospice care after hospitalization as a result of several medical conditions including but not limited to multiple pressure injuries on back, heels, and buttocks.

However, review of discharge records from Casitas Care Center did not indicate R1 having any pressure injuries. Discharge body check documented discoloration on the arms and redness on the thigh/groin. Review of hospice records revealed various inconsistencies between the documents obtained during the initial 10 day complaint visit, provided to Investigator Spindola and LPA Avetisyan. The 4/22/2020 RN visit record documented Head to toe Assessment performed. Vital signs were checked. Patient has pressures on Left Buttocks area, Mid lower back. Northridge Hospital medical records documented the following pressure injuries upon hospitalization. DTPI Left hip, Unstageable, left flank/back Upper back multiple DTPI wounds, Unstageable Sacrum-extending to bilateral buttocks , LLE skin tear with underlying hematoma vs DTPI, Unstageable Midback pressure injury, DTPI Right dorsal foot, Right medial foot and Right Posterior calf DTPI.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20200428160827
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: 06/25/2022
NARRATIVE
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Information obtained during the course of the investigation revealed that upon discharge from Casitas Care Center R1 did not have any medical documentation that included a diagnosis of pressure injuries. Licensee did not complete pre-placement appraisal or appraisal identifying pressure injuries upon admission. Hospice and Hospital records confirmed R1 developed multiple unstageable pressure injuries and Deep tissue pressure injuries while living at the facility therefore the allegation of Neglect/Lack of Care and Supervision is Substantiated.

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: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20200428160827
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: 06/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2022
Section Cited
CCR
87611(c)
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In addition to Section 87411(d), facility staff shall have knowledge and the ability to recognize and respond to problems and shall contact the physician, appropriately skilled professional, and/or vendor as necessary. This requirement was not being met as evidenced by: Based on Information obtained during the course of the investigation the
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Licensee/Administrator will submit a Detailed written explanation why they have been continuously operating non-compliant as evidenced by the various complaints received by the department.
Licensee/Administrator will also need to submit a detailed plan regarding the steps that will be taken to ensure compliance of
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facility staff did not comply with the cited section by not having knowledge and ability to properly document respond and obtain medical care of R1's various pressure injuries not being treated by the hospice agency which posed an immediate health and safety, and personal rights risk to resident in care.
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all deficiencies issued since licensure.

Licensee/Administrator will also provide in service training to all staff regarding the cited. Certification of the training will need to be submitted as POC.
Type A
06/27/2022
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. This requirement was not met as evidenced by. Based on information obtained during the course of the investigation the licensee/
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Licensee/Administrator will submit a Detailed written explanation why they have been continuously operating non-compliant as evidenced by the various complaints received at the department.
Licensee/Administrator will also need to submit a detailed plan regarding the steps that will be taken to ensure compliance of
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administrator did not comply with the cited section by not having knowledge of R1's various pressure injuries not being treated by hospice and ensuring proper medical care was obtained prior to hospitalization which posed an immediate health and safety, and personal rights risk to resident in care.
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all deficiencies issued since licensure.

This is a repeat citation therefore civil penalty in the amount of $250 dollars has been issued, civil penalty will continue to accrue until plan of correction is submitted to the LPA. First citation issued on 4/7/2022.
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: 06/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4