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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609793
Report Date: 01/27/2023
Date Signed: 01/27/2023 01:50:51 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
09/16/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20200916160807
FACILITY NAME:SAINT CLAIR ASSISTED LIVINGFACILITY NUMBER:
197609793
ADMINISTRATOR:ANI MKRTCHYANFACILITY TYPE:
740
ADDRESS:6608 SAINT CLAIR AVETELEPHONE:
(323) 793-8228
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Emma Arutiunian - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to safeguard resident’s personal items
Staff over medicated resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This is the new report for the report that was amended to make a correction for the report issued on 08/17/2021**
Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit for the above allegation. LPA met with Ani Gabrielian and explained the reason for the visit.

During the investigation, LPA conducted a physical plant tour virtually on 09/25/2020 as well as interviewed Administrator. Subsequent visits were also conducted on 6/7/2021 and 7/2/2021 to conduct interviews with facility staff, residents and other relevant parties. LPA also gathered and reviewed pertinent facility documentation relevant to the investigations during these visits. On 08/17/2021 LPA conducted medication audit for (3) out of the (5) residents in care at that time. On 12/5/2022, LPA interviewed the responsible party of Resident 1 (R1).

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 5
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
09/16/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20200916160807

FACILITY NAME:SAINT CLAIR ASSISTED LIVINGFACILITY NUMBER:
197609793
ADMINISTRATOR:ANI MKRTCHYANFACILITY TYPE:
740
ADDRESS:6608 SAINT CLAIR AVETELEPHONE:
(323) 793-8228
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is mishandling resident’s medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This is the new report for the report that was amended to make a correction for the report issued on 08/17/2021**
Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit for the above allegation. LPA met with Ani Gabrielian and explained the reason for the visit.

During the investigation, LPA conducted a physical plant tour virtually on 09/25/2020 as well as interviewed Administrator. Subsequent visits were also conducted on 6/7/2021 and 7/2/2021 to conducted interviews with facility staff, residents and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation during these visits. On 08/17/2021 LPA conducted medication audit for (3) out of the (5) residents in care at this time. On 12/5/2022, LPA interviewed the responsible party of Resident 1 (R1).

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 5
Control Number 29-AS-20200916160807
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
VISIT DATE: 01/27/2023
NARRATIVE
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5
6
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Continued from 9099

It was reported that staff is mishandling residents’ medications as it was alleged that staff provided the responsible party of Resident 1 (R1) medications of other residents in care. On 12/5/2022, LPA interviewed the responsible party for R1 who indicated that when they went to the facility to pick up R1, the responsible party requested R1’s medication from staff. The responsible party could not recall the staff members name at this time. Responsible party continued to state, the staff member brought them a bag filled with (4) different medications belonging to Resident 2 (R2), Resident 5 (R5) and Resident 6 (R6). LPA record review of clients roster and resident records revealed (3) of the prescribed medications listed belonged to R2 and R5, both of whom were listed on facility roster. Facility could not locate any records for R6 at this time. LPA interview with Staff 1 (S1) revealed R2 and R5 were residents of the facility in September 2020, but S1 does not recall R1 and R6. Based on information gathered during this and previous visits the department has sufficient evidence to determine this allegation occurred. Therefore, the allegation that Staff is mishandling resident medications while in care has been deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200916160807
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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2023
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
87465 (h)(2) Incidental Medical and Dental Care - Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee agreed to provide documentation of in service training regarding how to properly store medications with staff via email by COB 01/28/2023
8
9
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12
13
14
Based on information that Licensing received, R2 and R5’s prescribed medication were provided to the responsible party of R1 in error. This poses as an immediate health and safety risk to residents in care.
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4
5
6
7
1
2
3
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20200916160807
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
VISIT DATE: 01/27/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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18
19
20
21
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24
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32
Continued from 9099
It was reported that staff failed to safeguard R1s personal items as It was alleged that staff could not locate R1s clothing and tablet. On 12/5/2022, LPA interviewed the responsible party for R1 who indicated that facility staff could not locate a bag of clothes and a tablet. Interview with the responsible party further revealed that R1 was admitted to a local hospital prior to being discharged to this facility. The responsible party continued to state that they submitted a bag of clothing and tablet to that hospital. The responsible party can’t confirm if R1’s personal items ever made it into the facility and when they asked facility staff about the items, the staff stated they have not seen a bag of clothing or a tablet in R1’s possession. LPA interview with residents in care revealed that all did not express any concerns with staff being unable to keep their personal items safe. Based on information gathered during this and previous visits the department does not have any sufficient evidence to determine that staff failed to safeguard personal items. Therefore the allegation that staff failed to safeguard R1’s personal items has been deemed UNSUBSTANTIATED at this time.
It was reported that staff over medicated R1 while in care, as it was alleged that Staff administered medication to R1 that wasn’t prescribed to R1. On 12/5/2022, LPA interviewed the responsible party of R1 who stated when they went to the facility to pick up R1, that R1 seemed “really off” and not coherent. Responsible party was told by staff that R1 was given medication in the morning, however the responsible party could not confirm if medication was actually administered to R1. Interview with the responsible party further revealed they admitted R1 into a local hospital after they left the facility. The responsible party continued to state that the hospital staff did not indicate any potential or immediate concerns at that time. LPA interview with former Administrator Armenuhi Avetisyan revealed that R1 was only present in the facility for approximately one night. Armenuhi stated by the time they returned to the facility the next morning to complete their evaluation of R1, R1 was removed from the facility by their family member. On 08/17/2021, at approximately 2:30pm, LPA conducted a medication audit with Administrator and staff for (3) out of the (5) residents in care at that time. It appeared to indicate that the medications reviewed for Resident 2 (R2), Resident 3 (R3) and Resident 4 (R4) were administered as prescribed at this time. No medication record on file for R1 to review. Based on information gathered during this and previous visits the department does not have sufficient evidence to determine that staff over medicated R1 while in care. Therefore, the above allegation that Staff over medicated R1 while in care has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5