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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609788
Report Date: 12/20/2022
Date Signed: 12/20/2022 02:46:27 PM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20221215161509
FACILITY NAME:NORTHRIDGE GARDENS BOARD & CARE, INC.FACILITY NUMBER:
197609788
ADMINISTRATOR:KHACHATUROVA, GAYANEFACILITY TYPE:
740
ADDRESS:18915 LIEDAN STTELEPHONE:
(818) 917-5104
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 4DATE:
12/20/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Gayane Khachaturova, Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff made harmful items accessible to the residents while in care
Staff mishandled the residents medications while in care
INVESTIGATION FINDINGS:
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At 11:20am, Licensing Program Analysts (LPA) Angela Pnaushkina conducted an unannounced complaint visit to investigate the above noted allegation. LPA met with the Staff #1 (S1) and Staff #2 (S2) who granted access to the facility. Administrator was contacted and LPA explained the reason for the visit. Administrator arrived at 1:45pm.

It was alleged that "Staff made harmful items accessible to the residents while in care." To investigate this allegation, LPA conducted a physical walk though of the facility, interviewed Administrator and two (2) staff members between 11:30am-1:00pm. LPA also obtained copies of pertinent documents relevant to the investigation.

Upon arrival at 11:20am, LPA observed kitchen drawer with knives and sharp objects unlocked. LPA observed the lock on the kitchen drawer was broken and requested to change it, immediately. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
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 3
Control Number 31-AS-20221215161509
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788
VISIT DATE: 12/20/2022
NARRATIVE
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In addition, interviews with the Administrator confirmed that on November 30th, 2022, a random visit was made by a credible witness who observed an unlocked drawer in the kitchen containing knives and scissors Administrator informed LPA that an additional training will be provided to all facility staff members. Based on an interview conducted with the Administrator and LPA's observation this allegation is Substantiated at this time.

It was alleged that "Staff mishandled the residents medications while in care." Upon arrival, LPA observed the medication cabinet in the kitchen was unlocked and accessible to residents in care. Staff #1 (S1) immediately locked the medication cabinet. Based on the LPA's observation this allegation is Substantiated at this time.

Deficiencies were issued per CA code of Regulations Title 22 on LIC9099-D with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20221215161509
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2022
Section Cited
CCR
87705(f)(1)(2)
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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents...(1) Knives, matches, firearms...(2) Over-the-counter medication... cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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Administrator will provide a training to all staff on the importance of maintaining knives and chemical items inaccessible to residents in care. The administrator shall submit staff sign in sheet with the topic and the training material to LPA by POC date.
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Based on observation, the licensee did not comply with the section cited above by providing care and supervision to persons with dementia and having knives and cleaning solutions/chemicals unlocked and accessible to residents in care, which poses an immediate health and safety or pesonal rights risk to persons in care.
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Type A
12/22/2022
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place...

This requirement is not met as evidenced by:
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Licensee shall conduct in-house training with Administrator and all staff regarding regulation above. A written statement acknowledging the completion of training shall be submitted to the LPA by POC date
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Based on observation and interview, the licensee did not comply with the section cited above by keeping centrally stored medication cabinet unlocked, which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3