197609766-4-28-2023-31-AS-NMAN-CSYTEH-20230620143957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609766
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:12:31 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
04/21/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230421131329

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: 6	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Sona Gervorkyan		TIME COMPLETED:	11:54 AM

ALLEGATION(S):

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Facility staff failed to provide resident's records to an authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith conducted an initial complaint visit to this facility at 10:30 am. LPA Smith met with facility staff and disclosed the purpose of the visit and the administrator arrived later.
It was alleged that Facility staff failed to provide resident's records to an authorized representative. LPA Smith conducted physical plant tour at 10:50 AM, interviewed administrator at 11:00 am. Interview with the administrator revealed she did not receive a FedEx letter for R1s records. The administrator revealed she was contacted by telephone on 04/27/23 at 10:24 am from the corporate office requesting R1s records and she sent over 85 pages of records the same day. LPA Smith reviewed the administrators call history and the fax transmittal page dated 04/27/23 indicating 93 pages were sent to the corporate office. LPA Smith also contacted the corporate office at 11:52 am but was unable to get verbal confirmation that the records were received. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.
No citations issued. Exit interview conducted. Copy of this report issued

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: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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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