197609774-4-18-2022-29-AS-JAPL-CDTPQU-20220425113144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609774
Report Date: 04/18/2022
Date Signed: 04/18/2022 04:58:16 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2021 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20210115115722

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: 6	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nona Khachunts, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident wanders into another resident's room while in care

Staff hits a resident while in care

Resident is not properly fed while in care

Resident medications are not being administered while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint inspection for the above allegations. The LPA met with Nona Khachunts at 9:42 a.m., and explained the reason for the visit.

On 01/22/2021, LPA Aja Richardson initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with Administrator Nona Khachunts. At 1:45 pm, LPA Richardson conducted an interview with the Administrator as well as requested facility resident records. The LPA determined further investigation was required at that time.

Continue on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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-20210115115722

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: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
	VISIT DATE: 04/18/2022

NARRATIVE

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On 04/13/2022, LPA Salia Walker conducted a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with facility staff at 10:36 a.m., to ensure there are no health and safety hazards. From 11:00 a.m. until 12:13 p.m., the LPA conducted an interview with the administrator. From 12:13 p.m. until 12:45 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 12:45 p.m. until 1:30 p.m., the LPA conducted interviews with two (2) staff. The LPA determined further investigation was required at that time.

During today’s visit, the LPA conducted a physical plant tour with the administrator at 9:45 a.m., to ensure there are no health and safety hazards. From 9:22 a.m. until 9:26 a.m.; and between 12:00 p.m. until 12:14 p.m., the LPA conducted interviews with facility residents. From 9:55 a.m. until 12:00 p.m., the LPA along with the Administrator reviewed four (4) out of six (6) client medications. From 1:26 p.m. until 2:05 p.m., the LPA conducted telephone interviews with resident family members.

Regarding the allegation: Resident wanders into another resident's room while in care.
It was alleged that a facility resident would go freely into Resident #1 (R1’s) room. During the investigation, LPA Richardson conducted an interview with the administrator. LPA Walker also conducted interviews with the administrator, facility staff, and resident family members. The LPA also made multiple attempts to contact the complainant and obtain additional information pertaining to the allegation, however, was unsuccessful. Interviews with the administrator revealed that R1 and resident #2 (R2), ‘got along at first.’ However, due to R1’s decline in health condition R1 began not getting along with R2, and no longer allowed R2 in R1’s bedroom. The administrator denied claims of facility resident wondering into other resident rooms. Interviews with staff revealed that ‘no resident wonder into other rooms,’ and ‘staff are here to make sure no residents do not enter into other rooms.’ Interviews with resident family members revealed that during visits family members had not seen or observed other residents wondering into their family member’s rooms.

Based on interviews with the administrator, staff, and resident family members. There is insufficient evidence to support the allegation ‘Resident wanders into another resident's room while in care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.
Continue on LIC9099C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210115115722

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: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
	VISIT DATE: 04/18/2022

NARRATIVE

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Regarding the allegation: Staff hits a resident while in care.
It was alleged that R1 was being slapped by caregivers. To investigate the allegation the LPA attempted to contact the complainant, and obtain additional information pertaining to the allegation, however, was unsuccessful. During the investigation, LPA Walker conducted interviews with the administrator, facility staff, and resident family members. Interview with the administrator revealed that ‘staff treat residents with respect, and in a loving manner.’ Interviews with administrator, and facility staff revealed that they have not observed facility staff touching residents inappropriately. Interviews with resident family members revealed that ‘staff are great,’ and ‘staff treat residents with respect.’ Although It appears that there was an incident where R2 made a verbal threatened R1; the facility intervened, and resolved the issue at the time of occurrence.

Based on interviews with the administrator, staff, and resident family members. There is insufficient evidence to support the allegation ‘Staff hits a resident while in care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation: Resident is not properly fed while in care.
It was alleged that R1 was being refused food. To investigate the allegation the LPA attempted to contact the complainant, and obtain additional information pertaining to the allegation, however, was unsuccessful. During the investigation, LPA Walker conducted interviews with the administrator, facility staff, and resident family members. Interviews revealed that the facility provides residents ‘3 meals a day, including snacks,’ and ‘accommodate’ if residents request other meals. On 04/13/2022 and 04/18/2022, the LPA conducted a physical plant tour with the administrator, which included an inspection of the facility kitchen. The LPA observed a that the minimum requirement for seven (7) days’ worth of nonperishable food and two (2) days of perishable food was met. The LPA observed four (4) cabinets with an approximate minimum of 63 cans of fruit, 43 cans of vegetables, and 43 cans of meat.
Based on LPAs observation, and interviews with the administrator, facility staff, and resident family members. There is insufficient evidence to support the allegation ‘Resident is not properly fed while in care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.
Continue on LIC9099C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210115115722

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: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
	VISIT DATE: 04/18/2022

NARRATIVE

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Regarding the allegation: Resident medications are not being administered while in care.

It was alleged that R1 was being refused medications by the facility. During the visit on 04/18/2022, the LPA conducted a medication audit of four (4) out of six (6) residents. The LPA did not identify any medication errors during the medication audit. The LPA reviewed the file for R1 and was unable to identify any medication changes or adjustments. Interviews conducted with the administrator, and staff revealed that all residents are assisted with the self-administration of medication in a timely manner. Interviews with resident family member revealed that ‘The facility makes sure resident(s) are receive medication on time.’

Based on the information obtained, there is insufficient evidence to support the claim that R1 was not assisted with the self-administration of medication as prescribed. Therefore, there is insufficient evidence to support the allegation ‘Resident medications are not being administered while in care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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