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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609771
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:16:02 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230104102628
FACILITY NAME:ETERNAL LIFE SENIOR CARE FACILITYFACILITY NUMBER:
197609771
ADMINISTRATOR:AVETIKYAN, OLGAFACILITY TYPE:
740
ADDRESS:8112 CROSNOE AVENUETELEPHONE:
(818) 988-7878
CITY:VAN NUYSSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 4DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Olga Avetikyan, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident is not being bathed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 9:25 a.m., the LPA met with facility staff and explained the reason for the visit. At 9:44 a.m., the Administrator, Olga Avetikyan arrived at the facility.

During the initial visit on 01/12/2023, between 1:28 p.m. and 1:50 p.m., LPA Peraldi conducted a brief physical plant tour, interviewed the Administrator, and requested pertinent documents. On 01/12/2023, between 1:51 p.m. and 3:28 p.m., the LPA conducted one (1) staff interview, one (1) resident interview and two (2) resident family member’s interviews. Additionally, on 01/12/2023, at 3:22 p.m., the LPA attempted to interview three (3) residents. During today’s visit, between 9:45 a.m. and 10:15 a.m., the LPA conducted an interview with the Administrator and conducted a physical plant tour. At 10:22 a.m., the LPA also attempted to interview four (4) residents. Additionally, on 06/14/2023, the LPA reviewed pertinent documents such as resident’s admission agreements and physician’s report. Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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 5
Control Number 29-AS-20230104102628
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ETERNAL LIFE SENIOR CARE FACILITY
FACILITY NUMBER: 197609771
VISIT DATE: 06/14/2023
NARRATIVE
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Regarding the allegation: Resident is not being bathed. On 01/04/2023, the Department received a complaint alleging that Resident #1 (R1) had a foul smell and was not being bathed. Staff interviews conducted on 01/12/2023, stated that staff bathe residents twice a week. The staff explained that each resident has a different bathing schedule. On 01/12/2023 and on 06/14/2023, the Administrator stated that residents get a bathed twice a week and sometimes up to four (4) times, depending on the resident. The staff and the Administrator could not provide a bathing log or a documented bathing schedule to the LPA. The LPA conducted a record review on 06/14/2023 and noted the following: R1’s admission agreement states that the “Facility provides the resident with three baths/showers per week.” According to R1’s admission agreement, R1 is supposed to be receiving three baths/showers per week. The LPA was unable to confirm whether the residents, including R1 get bathed twice a week or three times a week. Additionally, interview conducted with R1’s family member confirmed that staff do not bathe R1 three times a week. During today’s visit the LPA had a conversation with the Administrator about the bathing logs and bathing schedule. The Administrator explained that they will work on filling out a bathing log and ensure that residents, including R1 will get bathed three times a week as per the admission agreements. Based on the information gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See LIC 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230104102628

FACILITY NAME:ETERNAL LIFE SENIOR CARE FACILITYFACILITY NUMBER:
197609771
ADMINISTRATOR:AVETIKYAN, OLGAFACILITY TYPE:
740
ADDRESS:8112 CROSNOE AVENUETELEPHONE:
(818) 988-7878
CITY:VAN NUYSSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 4DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Olga Avetikyan, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff smoke cigarettes on the premises
Staff failed to provide a comfortable environment for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 9:25 a.m., the LPA met with facility staff and explained the reason for the visit. At 9:44 a.m., the Administrator, Olga Avetikyan arrived at the facility.

During the initial visit on 01/12/2023, between 1:28 p.m. and 1:50 p.m., LPA Peraldi conducted a brief physical plant tour, interviewed the Administrator, and requested pertinent documents. On 01/12/2023, between 1:51 p.m. and 3:28 p.m., the LPA conducted one (1) staff interview, one (1) resident interview and two (2) resident family member’s interviews. Additionally, on 01/12/2023, at 3:22 p.m., the LPA attempted to interview three (3) residents. During today’s visit, between 9:45 a.m. and 10:15 a.m., the LPA conducted an interview with the Administrator and conducted a physical plant tour. At 10:22 a.m., the LPA also attempted to interview four (4) residents. Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230104102628
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ETERNAL LIFE SENIOR CARE FACILITY
FACILITY NUMBER: 197609771
VISIT DATE: 06/14/2023
NARRATIVE
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Regarding the allegations: Staff smoke cigarettes on the premises. Staff failed to provide a comfortable environment for residents. On 01/04/2023, the Department received a complaint alleging that the facility staff smoke cigarettes outside the facility and leave the door open, allowing smoke to enter inside the common areas. The complainant alleged that staff failed to provide a comfortable environment for the residents by allowing the smoke to enter the house. On 01/04/2023, the LPA observed one (1) staff smoking outside in the backyard and the back door was observed to be closed. Staff interviews conducted on 01/12/2023, stated that staff only smoke on their breaks and lunch time and in the facility’s designated smoking area. On 01/12/2023 and on 06/14/2023, the Administrator stated that when staff go smoke outside, that they always close the door, to ensure no smoke enters the facility. During both visits on 01/12/2023 and 06/14/2023, the LPA observed staff cleaning and mopping the common areas and residents’ rooms. The LPA also observed the inside temperature being maintained at a comfortable level. The LPA observed common area to be relatively clean and properly furnished. Additionally interviews with resident’s family members did not bring up concerns regarding the above allegations. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20230104102628
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETERNAL LIFE SENIOR CARE FACILITY
FACILITY NUMBER: 197609771
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
87464(f)(4)
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87464(f)(4) Basic Services. Basic services shall at a minimum include: (4)Personal assistance and care as needed by the resident...those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.This requirement is not met as evidenced by:
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Administrator agreed to submit a Statement of Understanding demonstrating how all facility staff, will bathe residents to meet their needs by 06/15/2023.
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 Based on interviews and record review, R1 did not receive three baths/showers a week as indicated in their admission agreement. This poses a immediate health and safety risk to residents in care.
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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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5