197609774-7-6-2023-29-AS-KHEN-D6N7Q3-20240627215113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609774
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:35:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
06/30/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230630104441

FACILITY NAME:	ST KATHERINE ASSISTED LIVING		FACILITY NUMBER:	197609774
ADMINISTRATOR:	NONA KHACHUNTS		FACILITY TYPE:	740
ADDRESS:	6862 KATHERINE AVENUE		TELEPHONE:	(818) 422-0245
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 4	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Nona Khachunts, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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4. Reporting Requirements - Facility did not report the resident's fall

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit and a health and safety check to ensure that there are no immediate concerns with the residents. LPA Yee was let into the home by Nvrard Manokian, Staff. Nona Khatchunts, Administrator, was contacted via telephone and arrived
at 12:37pm to conduct the visit. The Administrator was advised of the reason for today's visit.

On today's visit, LPA Yee conducted a tour of the physical plant at 1:43pm, reviewed facility food at
2:02pm, reviewed facility documents at 1:28pm. Per Administrator, Resident #1's facility file was sent with Emergency personnel when resident was sent to the hospital on 6/23/23 and has not been able to be recovered and is lost. Copies of available facility files will be scanned and emailed to IB Investigator, Laura Garcia and cc'd to LPA Yee.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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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Control Number 29-AS-20230630104441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
	VISIT DATE: 07/06/2023

NARRATIVE

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Upon entry into the home, Resident #2, Resident #4 and Resident #5 were observed sitting in the living room and later was observed participating in board games with staff and had lunch at 1:00pm. Resident #3 had lunch in own room. Visually, all the residents looked well. Per tour of the facility, no immediate safety concerns were observed and there were sufficient perishable and non-perishable foods on the premises.

Per interview conducted with the Administrator regarding Allegation #4 - Reporting requirements - the facility did not report resident's fall, the Administrator indicated that the Special Incident report(LIC624) was completed. The Administrator admitted that Resident #1 had a fall in the hallway after exiting the bathroom. Due to fax problems the Administrator also indicated that she did not follow up to ensure that the incident report was sent or received by licensing. Fax status reports were requested to establish that there were fax errors or fax failures to establish actual attempts were made to fax the Special Incident Report to Licensing and fax status reports could not be provided. There was no evidence that any attempts were made to report the fall incident to Licensing other than the LIC624 was completed.

Based on information received on today's visit, Allegation #4-Reporting Requirements - The facility did not report resident's fall, the allegation is substantiated.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights discussed and a copy was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230630104441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/13/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission, date and nature	1 2 3 4 5 6 7	Licensee will read Section 87211-Reporting Requirements and submit a SIGNED statement that the section was read and understood and that the facility will adhere to the reporting requirements at all times.
	8 9 10 11 12 13 14	of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Licensee did not report Resident #1's fall	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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