<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609793
Report Date: 07/22/2021
Date Signed: 07/22/2021 12:52:49 PM



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
06/28/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210628095819
FACILITY NAME:SAINT CLAIR ASSISTED LIVINGFACILITY NUMBER:
197609793
ADMINISTRATOR:ARMENUHI AVETIYANFACILITY TYPE:
740
ADDRESS:6608 SAINT CLAIR AVETELEPHONE:
(818) 983-2224
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Ani Gabrielian, DesigneeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have a current administrator
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit. The LPA met with Ani Gabrielian and explained the reason for the visit. During the visit, the LPA conducted a physical plan tour at 12:15 p.m. and spoke with Ani Gabrielian.

Regarding the allegation: Facility does not have a current administrator
It was alleged that the Facility does not have a current administrator. On June 28, 2021 between 01:30 p.m. and 03:30 p.m., the LPA conducted an interview with the prior administrator who stated that she had resigned as administrator though did not provide a specific date of when her employment ended. The previous administrator provided paperwork for Change of Administrator that was submitted on July 1, 2021. Therefore, there is sufficient evidence to support the allegation that the facility did not have a current administrator. This allegation is deemed SUBSTANTIATED at this time. Deficiencies cited on 9099-D.
Exit interview conducted. A copy of the report and appeal rights were provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 2
Control Number 29-AS-20210628095819
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: SAINT CLAIR ASSISTED LIVING
FACILITY NUMBER: 197609793
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2021
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411(a) Personnel requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee has agreed to do the following: Licensee will submit additional forms LIC 308 Designation of Administrator Responsibility, and LIC 500 Personnel Report to LPA, in order to complete the Change of Administrator by 07/26/2021.
8
9
10
11
12
13
14
Based on interviews and documents reviewed, the licensee did not comply with the section cited above. As the licensee failed to ensure there was an adequate amount of staff, which poses a potential health and safety risk to residents in care.
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2