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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609771
Report Date: 07/09/2024
Date Signed: 07/30/2024 04:00:20 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/02/2024 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20240702091428
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: 5DATE:
07/09/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Viktorya HayrapetyanTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff overmedicated resident.
Staff did not ensure facility phone was answered.
INVESTIGATION FINDINGS:
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This is an amended report to reflect the finding for the second allegation that was inadvertently left out on LIC9099 C. Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a subsequent visit to deliver findings for the allegations listed above. The LPA was greeted by staff and informed them of the reason for the visit. Facility representative Viktorya Hayrapetyan was unable to come to the facility. LPA Urena read the report to the administrator and allowed facility representative to sign the report.

On 07/03/204, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct an initial 10-day visit to investigate the allegations listed above. LPA Urena interviewed staff, resident and administrator at approximately 9:45 a.m. and 11:57 a.m. and collected records pertinent to the allegation. LPA interviewed the resident's responsible party at 1:30 p.m.
Continues on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
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 2
Control Number 29-AS-20240702091428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ETERNAL LIFE SENIOR CARE FACILITY
FACILITY NUMBER: 197609771
VISIT DATE: 07/09/2024
NARRATIVE
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Report is amended to include closing paragraph with findings for second allegation below.

Staff over medicated resident.On the allegation that the ‘Staff over medicated resident’, it is the concern of the complainant that R1 was receiving unnecessary medications and that R1 appeared drugged, barely able to speak or eat as R1 appeared to be unable to hold bread or utensils, is unable to fully open their eyes, and is speaking gibberish. To investigate the allegation, the LPA reviewed the Centrally Stored Medication and Destruction Record (LIC 622) and compared against the list of medications ordered by R1’s physician. All medications listed in the LIC 622 and the physician’s orders matched. Additionally, the LPA conducted a medication audit of the medications (the quantity of pills) which matched the count as of the start date of assisting with the medications, and as listed in the LIC 622. The interview with R1’s responsible party (RP) revealed that the medications were prescribed by R1’s primary physician. The RP added that the physician was made aware of the reaction to a specific medication, and the physician removed the medication that may have caused the drowsiness. The LPA spoke with one of R1’s family members on 07/08/2024, and the family member stated that R1 was back to their normal self and no longer appeared confused or drugged. Based on the information gathered through interviews and record review, the allegation of Staff over medicated resident, is deemed Unsubstantiated at this time.

Staff did not ensure facility phone was answered.On the allegation that ‘Staff did not ensure facility phone was answered’, it is the concern of the complainant that they attempted to reach staff at the facility, and tried three different times but was unable to get through. Complainant was hung up on during one of the calls. To investigate the allegation, LPA Urena interviewed staff(S1), regarding the facility staff not answering the phone, S1 stated that the phone is always answered. When the LPA asked why anyone would say that the phone was not answered, the S1 stated that often times the staff are busy caring for residents, changing the residents’ diapers, etc. and staff may not be able to answer the phone. The LPA called the phone number registered for the facility to test and see if the phone ring tone was loud enough to be heard by staff. The phone worked fine, and staff answered. The LPA interviewed the R1’s RP about the facility phone, and the RP stated that R1 cannot hold the phone or speak coherently, and they have never had a problem communicating with the facility and stated, ‘I am here with R1 at the facility almost every day, since R1 was admitted to the facility; I am happy with the care the caregivers are providing to R1’. Based on the information gathered through interviews and record review, the allegation of Staff did not ensure facility phone was answered’, is deemed Unsubstantiated at this time. LPA Urena emailed LIC9099 C to licensee to sign and return. Exit interview was conducted, and a copy of the report was issued.



SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
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