197609845-12-29-2023-29-AS-KHEN-CYZ2SX-20231229163953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609845
Report Date: 12/29/2023
Date Signed: 12/29/2023 10:54:08 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
12/06/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20211206110628

FACILITY NAME:	SWEET HOME SENIOR LIVING FACILITY		FACILITY NUMBER:	197609845
ADMINISTRATOR:	NARE NERSISYAN		FACILITY TYPE:	740
ADDRESS:	6456 VARNA AVENUE		TELEPHONE:	(818) 666-7598
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	12/29/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lusine Srmikyan, Licensee, Marine Bekyan,		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Questionable death.
Resident not accorded dignity in relationship with staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 9:45 a.m., the LPA met with staff and explained the reason for the visit. At 10:15 a.m., the Licensee and Coordinating Manager arrived at the facility.

During the initial visit conducted on 12/07/2021 between 12:00 p.m. and 3:45 p.m., LPA Peraldi conducted an interview with the Licensee, conducted physical plant tour and obtained copies of pertinent documents.
On 12/06/2021, a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) however, the referral was not accepted. On 12/10/2021, at 1:50 p.m., LPA Peraldi conducted a telephonic interview Resident #1 (R1’s) Power of Attorney (POA). On 12/06/2021, 12/10/2021 and 03/03/2022, the LPA conducted a telephonic interviews with the complainant. Additionally, on 12/10/2021 and 03/28/2022 the LPA reviewed R1’s records. Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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-20211206110628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SWEET HOME SENIOR LIVING FACILITY	FACILITY NUMBER: 197609845
	VISIT DATE: 12/29/2023

NARRATIVE

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Regarding the allegation: Questionable death. On 12/06/2021, the Department received a complaint alleging that the facility caused the death of Resident #1 (R1) by overdosing R1 with morphine. Per record review, R1 was admitted to the facility on 09/28/2021 and received hospice services up until R1’s death on 12/01/2021. Per record review, R1’s Doctor’s Worksheet for Certificate of Death listed R1’s cause of death A) Cardiorespiratory arrest B) Dementia lewy body C) Atherosclerosis heart disease D) HTN. Record review of R1’s Pathology report dated 03/21/2022 did not include any abnormalities that could be a raise for concern. Interview with R1’s POA on 12/10/2021 did not raise any concerns regarding the care of R1. R1’s POA stated that R1’s POA was at the facility every day prior to R1’s death and had no issues with the intake of R1’s morphine. R1’s POA stated that R1’s POA communicated with R1’s doctors and hospice agency regarding R1’s medication and R1’s POA was in charge of R1’s medical care. Interview with the Licensee revealed that R1’s POA was very involved in R1’s care and medical care. The Licensee stated that the amount of morphine was given to R1 as instructed by R1’s doctor. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident not accorded dignity in relationship with staff. On 12/06/2021, the Department received a complaint alleging that the facility staff were "mean" to Resident #1 (R1). Interview with R1’s POA on 12/10/2021 did not raise any concerns regarding the treatment of R1. R1’s POA stated that the facility staff were “wonderful and the care was phenomenal.” Interview with the Licensee did not reveal any issues between staff and R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC9099 (FAS) - (06/04)

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