197609814-8-17-2023-31-AS-TAGD-CW4T6N-20230928142725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609814
Report Date: 08/17/2023
Date Signed: 08/17/2023 10:43:11 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
11/15/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20211115151602

FACILITY NAME:	LAND OF PEACE 2		FACILITY NUMBER:	197609814
ADMINISTRATOR:	ZAKHARYAN, TIGRAN		FACILITY TYPE:	740
ADDRESS:	6636 SALE AVENUE		TELEPHONE:	(818) 704-9174
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 6	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Sona Muradyan - Administrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Residents in care sustained multiple pressure injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegation. LPA met with Administrator Sona Muradyan and explained the reason for the visit.

On 11/15/21 a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigations Branch (IB) but did not meet the criteria for full investigation.

On 11/15/21 at 1:00 PM, then LPA Jackson initiated the complaint visit. LPA conducted physical plant tour, interviewed staff and residents and obtained copies of the facility records relevant to the investigation.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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 31-AS-20211115151602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAND OF PEACE 2	FACILITY NUMBER: 197609814
	VISIT DATE: 08/17/2023

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that residents in care sustained multiple pressure injuries, it was alleged that Residents #1 and #2 (R1 and R2) had multiple bed sores with broken skin on their bottoms. LPA’s record review on 10/29/22 at 11:00 AM revealed that R1 was admitted at the facility on 07/29/2020 and was on hospice care since 12/30/2020. Further review also revealed that R1 had no pressure wound during the time in question (11/10/21) but has a traumatic wound on right forearm that the hospice agency was taking care of. LPA’s record review also revealed that R2 was admitted at the facility on 01/29/21 and had stage three (3) pressure sores that were being taken care of by the home health agency wound care nurse since R1 was admitted at the facility. Further review also revealed that the home health agency nurse/staff was visiting R1 seven (7) days a week and cleaned R1’s wound three (3) to four (4) times a day.

LPA’s interview with staff on 10/29/22 between 10:30 AM to 1:00 PM revealed that residents who were incontinent were being checked regularly. An interview with three (3) aware residents confirmed that staff checked them and change their diapers regularly.

Based on the information gathered during the course of the investigation, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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