197609774-6-21-2023-29-AS-JAPL-CUA53E-20230731193548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609774
Report Date: 06/21/2023
Date Signed: 06/21/2023 04:52:55 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
06/19/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230619135357

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: 5	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	11:44 AM
MET WITH:	Arev Misakyan, Staff		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff did not provide resident prompt access to their records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) conducted an unannounced complaint visit to investigate the above allegation and was let into the home by Arev Misakyan, Staff. Staff contacted Nona Khatchunts, Administrator to advise that Licensing was at the facility. Administrator was at the hospital and was not able to be at the facility due to a family emergency. The Administrator participated in todays visit via cell phone. The reason for today's visit was explained.

On today's visit, LPA Yee interviewed Nona Khatchunts, Facility Administrator at 12:03pm, the reporting party at 1:23pm and attempted to interview Titan Legal Services, Inc at 1:55pm and at 2:33pm and was not successful

Per information obtained during the visit and review of records, the facility was served legal documents from a law firm that was retained by Resident #1's family to obtain Resident #1's facility files. The

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: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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-20230619135357

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: 06/21/2023

NARRATIVE

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Authorization to release of records was dated 6/1/23 and a check dated 6/7/23 were hand delivered to the facility by a copying services company, Titan Legal Services, Inc on 6/9/23. Also included in the package delivered on 6/9/23 were a Authorization to Handle Claim, HIPAA Compliant Authorization for the Release of Patient Information Pursuant to 45 CFR 164.596, Certification of Vital Record, Declaration of family member as successor to Resident #1, a copy of family members Driver License and a Declaration of Custodian 0f Records. Per the Administrator, the request and documents included in the package were confusing. Per the Administrator, she was not sure whose documents were being requested since there was a copy of a Driver License belonging to someone who was much younger than the usual facility resident. The Administrator reached out to Titan Legal Services on 6/14/23 and spoke to a female staff. The Administrator does not remember the name of the female that she spoke with at Titan Legal Services to clarify the file being requested and the availability of those documents at the facility. Per the Administrator, she informed this person, that she did not have young residents and requested time from the copying company to review her records. While this was occurring, the Administrator did not contact the law firm requesting Resident #1's file and relied on her contact with Titan Legal Services, Inc regarding the time allowed to produce the documents requested. Per the information obtained from staff at the law firm they also made attempts to reach the Licensee on 6/13/23 and 6/19/23 and were not able to leave a message as the voicemail was full. Law firm staff handling the collection of documents for this case also denied that they spoke with the Administrator. Per law firm staff, they would have gladly clarified the documents being requested if the Administrator had called them.

As a result of the Administrator's confusion with whose documents were being requested and the failure to timely follow up with the production of Resident #1's file within 2 business days, the above allegation is substantiated.

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

Exit interview was conducted with the Administrator via telephone and Arev Misakyan was provided with a copy of the licensing report.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230619135357

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: 06/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access	1 2 3 4 5 6 7	The Licensee will immediately contact the contact person at the law firm/Titan Legal Services to schedule a time when they may have access to Resident #1's file for copying. Licensee will provide a signed statement to Licensing when the records are available for copying or the time when the records will be
	8 9 10 11 12 13 14	to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. Facility failed to provide timely access to Resident #1's records as requested by family.	8 9 10 11 12 13 14	copied by POC date - 6/28/23,
	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: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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