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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609774
Report Date: 06/19/2024
Date Signed: 06/19/2024 11:21:52 AM

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
06/30/2023 and conducted by Evaluator Christine Yee
COMPLAINT CONTROL NUMBER: 29-AS-20230630104441
FACILITY NAME:ST KATHERINE ASSISTED LIVINGFACILITY NUMBER:
197609774
ADMINISTRATOR:NONA KHACHUNTSFACILITY TYPE:
740
ADDRESS:6862 KATHERINE AVENUETELEPHONE:
(818) 422-0245
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nona Khachunts, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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1. Neglect: resident is severely malnourished
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Yee met with Nona Khachunts, Administrator and explained the reason for the visit.

On 06/30/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Care. It was alleged that Resident #1 (R1) was observed to be severely malnourished during a hospital visit on 06/23/2023.

The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laura Garcia.

On 07/06/2023, from 12:01pm to 3:40pm, Licensing Program Analyst (LPA) Christine Yee conducted an
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774
VISIT DATE: 06/19/2024
NARRATIVE
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unannounced complaint visit and a health and safety check to ensure that there were no immediate concerns with the residents. LPA Yee was let into the facility by Nvard Manukian, staff. Nona Khachunts, administrator, was contacted via telephone and arrived at 12:37pm to conduct the visit. The administrator was advised of the reason for the visit. During the visit, the LPA conducted a tour of the physical plant at 1:43pm, reviewed facility food at 2:02pm, and reviewed facility documents at 1:28pm. Per the administrator, Resident #1's (R1’s) facility file was sent with the Emergency personnel when R1 was sent to the hospital on 6/23/2023 and has not been able to be recovered and is lost. Copies of the available facility files will be scanned and emailed to the IB Investigator, Laura Garcia and cc'd to LPA Yee. The LPA determined further investigation was required prior to issuing findings.

Investigator Garcia conducted interviews on 07/05/2023, at approximately 11:30am, with the administrator; on 09/12/2023, from approximately 12:00pm to 2:00pm, with the administrator and caregivers; on 09/13/2023, from approximately 12:00pm to 3:30pm, with hospice nurses and resident representatives; and on 09/25/2023, at approximately 12:30pm, with the hospital social worker. In addition, the investigator reviewed R1’s Encino Hospital medical records, Divine Hospice notes, and limited facility file documents, including food receipts and text messages related to R1, as the complete file was not available. The Sherman Oaks medical records were requested, to date, no records have been received.

A copy of R1’s physician’s report was reviewed. The physician’s report dated 03/20/2023, stated that R1 had mild cognitive impairment, however, was able to feed self, had a special diet listed as a RCS mechanical soft diet, able to follow instructions, communicate needs, bowel and bladder impaired, required continuous bed care, and was considered non-ambulatory based on physical condition. R1 was admitted to the facility on 03/21/2023 already receiving hospice services through Divine Hospice Care. The primary hospice diagnosis was listed as kidney disease. Hospice notes also indicate R1 was a fall risk and had a DNR (do not resuscitate) order.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774
VISIT DATE: 06/19/2024
NARRATIVE
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According to the investigation, R1 was admitted to Sherman Oaks Hospital on 06/23/2023, due to a decline and unresponsive. Hospital notes indicate R1 was observed to be of an average height (approximately 5’6”) and was observed to be severely malnourished, weighing 90 lbs. The “resident is skin and bones.” Per the administrator, on 06/23/2023, R1 was observed to be extremely ill and refused to have any food. R1 became unresponsive and was immediately sent to Sherman Oaks hospital via ambulance. The administrator indicated that R1 did not return to the facility due to passing away at Sherman Oaks Hospital. Text messages between R1 and administrator revealed on 06/17/2023 at 11:34am, R1 requested the status of their fast-food order. The administrator also provided receipts for R1’s fast food purchases. The administrator indicated they would continuously offer R1 food and water at different times of the day, however, R1 would mostly refuse to eat. The administrator indicated that hospice nurses were aware of R1’s lack of appetite and instructed them to just continue with offering food and liquids. The hospice nurses described R1’s health as declining and confirmed they continuously witnessed the staff offer R1 food and liquids, however, due to R1’s health condition, R1 would often refuse.

On the allegation “Neglect/Lack of Care - Resident was severely malnourished”. According to the hospital personnel, R1 was observed to be extremely thin and malnourished. R1 was receiving hospice/palliative care and with a current DNR (do-not-resuscitate) order. Per the hospice nurses and facility staff, R1 was continuously being offered food, which also included ordering take out (receipts were provided by the facility) and liquids at different hours of the day, but due to R1’s health condition, would often refuse to eat. The facility administrator notified the hospice nurse with updates on R1’s condition and R1’s refusal to eat. Based on statements provided and the medical condition of R1, there is insufficient evidence to support the allegation of Neglect/ Lack of Care related to malnourishment. Therefore, the allegation “Neglect/Lack of Care - Resident was severely malnourished” is deemed unsubstantiated at this time.

Exit interview conducted, and a copy of this report issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8
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
06/30/2023 and conducted by Evaluator Christine Yee
COMPLAINT CONTROL NUMBER: 29-AS-20230630104441

FACILITY NAME:ST KATHERINE ASSISTED LIVINGFACILITY NUMBER:
197609774
ADMINISTRATOR:NONA KHACHUNTSFACILITY TYPE:
740
ADDRESS:6862 KATHERINE AVENUETELEPHONE:
(818) 422-0245
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nona Khachunts, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2. Neglect: facility failed to provide timely medical attention
3. Neglect: facility retained a resident with an unstageable dermal ulcer
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Yee met with Nona Khachunts, Administrator and explained the reason for the visit.

On 06/30/2023, the Department received a complaint regarding allegations of Neglect/Lack of Care. It was alleged that Resident #1 (R1) sustained an unstageable pressure injury while in facility care and the facility failed to provide R1 medical attention in a timely manner. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laura Garcia.

On 07/06/2023, from 12:01pm to 3:40pm, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit and a health and safety check to ensure that there were no immediate
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774
VISIT DATE: 06/19/2024
NARRATIVE
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concerns with the residents. LPA Yee was let into the facility by Nvard Manukian, staff. Nona Khachunts, administrator, was contacted via telephone and arrived at 12:37pm to conduct the visit. The administrator was advised of the reason for the visit. During the visit, the LPA conducted a tour of the physical plant at 1:43pm, reviewed facility food at 2:02pm, and reviewed facility documents at 1:28pm. Per the administrator, Resident #1's (R1’s) facility file was sent with the Emergency personnel when R1 was sent to the hospital on 6/23/2023 and has not been able to be recovered and is lost. Copies of the available facility files will be scanned and emailed to the IB Investigator, Laura Garcia and cc'd to LPA Yee. The LPA determined further investigation was required prior to issuing findings.

Investigator Garcia conducted interviews on 07/05/2023, at approximately 11:30am, with the administrator; on 09/12/2023, from approximately 12:00pm to 2:00pm, with the administrator and caregivers; on 09/13/2023, from approximately 12:00pm to 3:30pm, with hospice nurses and resident representatives; and on 09/25/2023, at approximately 12:30pm, with the hospital social worker. In addition, the investigator reviewed R1’s Encino Hospital medical records, Divine Hospice notes, photos of R1’s pressure injury and right heel blister, and limited facility file documents related to R1, as the complete file was not available. The Sherman Oaks medical records were requested, to date, no records have been received.

A copy of R1’s physician’s report was reviewed. The physician’s report dated 03/20/2023, stated that R1 had mild cognitive impairment, however, was able to follow instructions, communicate needs, bowel and bladder impaired, required continuous bed care, and non-ambulatory based on physical condition. R1 was admitted to the facility on 03/21/2023 already receiving hospice services through Divine Hospice Care. The primary hospice diagnosis was listed as kidney disease. Hospice notes also indicate R1 was a fall risk.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774
VISIT DATE: 06/19/2024
NARRATIVE
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According to the investigation, R1 was admitted to two hospitals. The first admission was on 05/23/2023 at Encino Hospital due to a witnessed fall on 05/19/2023 that resulted in R1 sustaining a hip fracture. Upon admission to Encino Hospital, R1’s sacral wound was observed. It was noted that R1 was not able to bear weight for 1 to 2 weeks prior to being taken to the Encino ER. Hospital progress notes dated 05/23/2023 document pressure induced deep tissue injury of sacral region. R1 had hip surgery on 05/25/2023 and was discharged back to the facility on 06/06/2023 with wound care instructions. The second hospital admission was on 06/23/2023, at Sherman Oaks Hospital via emergency ambulance due to R1 declining and being unresponsive. It was also noted on the hospital admission that R1 had an unstageable pressure injury. Further research revealed R1 was scheduled to have the pressure injury debrided on 06/29/2023. Per the administrator, R1 did not return to the facility due to R1 passing away at Sherman Oaks Hospital.

On the allegation “Neglect/Lack of Care - Resident sustained a pressure injury while in care”. During the course of the investigation, documentation from Divine Hospice and medical records from Encino Hospital were obtained and reviewed. On 05/23/2023, R1 was admitted to the hospital due to a hip fracture. Upon admission to the hospital and during a body assessment, hospital staff observed skin maceration/a deep tissue injury (DTI) to the sacral area extending to R1’s left buttocks and a blister to R1’s right heel. Additionally, upon hospital admission, R1 was able to report that R1 had sustained a fall and could not walk or bear weight for several days after the fall. On 05/25/2023, R1 underwent hip surgery. According to records, the sacral wound was determined to be in “evolution” and worsened to “Unstageable” possibly due to immobilization while at the hospital. On 06/06/2023, R1 was discharged back to the facility, with wound care instructions. The staff denied noticing any wound prior to R1 being hospitalized. However, while speaking with the hospice nurse, they indicated that a possibility exists that due to the R1’s fall incident on 05/19/2023, coupled with malnourishment and incontinence, the pressure wound could have developed and gone unnoticed. When asked specific questions focusing on dates and times of R1’s movements (rotation, body checks), staff were unable provide specifics.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774
VISIT DATE: 06/19/2024
NARRATIVE
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The staff denied noticing any skin changes on R1, however, staff was not able to provide specific details or notes on R1’s body checks or the status of R1’s mobility after the fall, this could have led to a pressure wound developing. Based on the above information, medical photographs, and the hospital wound care specialist’s notes, there is sufficient evidence to support the allegation of Neglect/ Lack of Care by the facility. Therefore, the allegation “Neglect/Lack of Care - Resident sustained a pressure injury while in care” is deemed substantiated at this time.

On the allegation “Neglect/Lack of Care - Facility failed to provide medical attention in a timely manner”. On 05/23/2023, at the Encino Hospital ER, R1 reported that R1 sustained a recent fall at the facility and was not able to walk or bear weight. The facility administrator confirmed that on 05/19/2023, caregivers witnessed R1 lose their balance and fall to the floor. According to staff, medical aid was not rendered because R1 appeared to be well and had no indication of pain. On 05/22/2023, during morning routine, staff noticed that R1 was in severe pain and unable to move. On 05/22/2023, a hospice nurse visited and ordered an x-ray. On 05/23/2023, an x-ray was performed on R1, and revealed that R1 had sustained a fracture. R1 was admitted to the hospital on 05/23/2023 and underwent hip surgery. Based on the above statements, admission that the fall was unreported, and failure to seek immediate medical attention, there is enough evidence to substantiate the allegation of Neglect/ Lack of Care. Therefore, the allegation “Neglect/Lack of Care - Facility failed to provide medical attention in a timely manner” is deemed substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator/Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2024
Section Cited
HSC
1569.312(a)
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Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.
This requirement is not met as evidenced by:
Based on medical records, photos, and interviews, the licensee did not comply with the section cited above. Facility
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The licensee will submit a plan on how the facility will ensure 24-hour care and supervision to meet the needs of the residents. Submit to CCL by 6/20/24
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staff failed to provide the necessary care and supervision which resulted in R1 sustaining a pressure injury while in care, which posed an immediate health and safety risk to residents in care. Immediate Civil Penalties were assessed.
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Type A
06/20/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist
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The licensee will submit a plan on how you will ensure you will provide timely medical attention for residents in care. Submit to CCL by 6/20/24
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 in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on medical records, photos, and interviews, Facility staff failed to report R1’s 05/19/2023 fall and failed to seek immediate medical attention, which posed an 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) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8