197609829-7-17-2023-29-AS-KHEN-CUHUJV-20230808153811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609829
Report Date: 07/17/2023
Date Signed: 07/17/2023 04:50:09 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
07/12/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230712110352

FACILITY NAME:	ARARAT BOARD AND CARE		FACILITY NUMBER:	197609829
ADMINISTRATOR:	SARGSYAN, KARINE		FACILITY TYPE:	740
ADDRESS:	6614 TEESDALE AVE		TELEPHONE:	(818) 624-4180
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Mariam Panadhzyan, Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff moved resident without notifying residents authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and met with Mariam Panadhzyan, Licensee. The Administrator, Karine Sargsyan was not present for this visit. The reason for today's visit was explained.

On today's visit, LPA Yee obtained copies of facility records at 10:08am, conducted interview with Mariam Panadhzyan at 11:22am and attempted to interview the conservator at 11:56am and at 1:44pm.

The investigation revealed the following: Per the Licensee, Resident #1 initially moved into the facility on 4/15/23 and was hospitalized on 5/20/23 and later transferred to skilled nursing facility. Resident #1 was discharged back to the facility on 6/4/23. Resident #1 would have loud arguments with Resident #7, roommate. Per the Licensee, they would argue about the lights, bathroom and Resident #1 would accuse

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: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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 29-AS-20230712110352

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: ARARAT BOARD AND CARE	FACILITY NUMBER: 197609829
	VISIT DATE: 07/17/2023

NARRATIVE

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Resident #7 of stealing their clothes. Per the Licensee, with the constant fighting and arguments, she felt that she couldn't provide care to the residents. The Licensee stated that she informed Resident #1 about the private room at the now identified unlicensed location so that Resident #1 could have own room. The Licensee took Resident #1 for a tour the unlicensed facility. Resident #1 loved the unlicensed home and and their belongings were moved by the Licensee to the new location on 6/9/23. The only item remaining at this facility is Resident #1's hospital bed. Per Licensee, Resident #1 informed her that they had no family but had someone who had the authority to make medical decisions for them. Licensee did not request any legal documents from the resident for verification about the person who could make medical decision. Licensee relied on Resident #1's information that they had no family and made no attempts to contact anyone, including the person who had the authority to medical decisions about the relocation. Per the Licensee, Resident #1 was very alert and was able to make own decisions.

During today's visit, LPA Yee attempted to conduct an interview with the Conservator at the telephone number provided at 11:56am and at 1:44pm. Per the outgoing telephone message, the number belongs to the office of the Los Angeles Public Guardian. Based on the information obtained from today's investigation, the above allegation is substantiated.

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

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was given.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230712110352

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: ARARAT BOARD AND CARE	FACILITY NUMBER: 197609829
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/24/2023 Section Cited CCR 87211(f)(1)	1 2 3 4 5 6 7	Reporting Requirements:Failure to comply with Section 87211(d), or Section 87211(e), or both, may result in a civil penalty of one hundred dollars ($100) for each day of the failure to provide the required notification, not to exceed two thousand dollars ($2,000)1) If a resident is relocated without the specified notification, and the resident suffers transfer trauma	1 2 3 4 5 6 7	The Licensee will review Title 22, Section 87211 and provide a signed written statement indicating that the section was read and understood and that the facilty will adhere to the regulations by 7/24/23
	8 9 10 11 12 13 14	as defined in Section 87101, or other harm to their health or safety, the Department may suspend or revoke the license or other specified actions pursuant to Health and Safety Code section 1569.686(c) Licensee did not notify Resident #1's Conservator of relocation	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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

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