197609860-11-16-2022-31-AS-RRAZ-CLM86M-20221128211430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609860
Report Date: 11/16/2022
Date Signed: 11/16/2022 11:23:23 AM

Substantiated

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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2022 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20221109141505

FACILITY NAME:	AMAZING SENIOR CARE, INC		FACILITY NUMBER:	197609860
ADMINISTRATOR:	ANNA PETROSYAN		FACILITY TYPE:	740
ADDRESS:	16938 CITRONIA STREET		TELEPHONE:	(818) 853-6695
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	11/16/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Yelen Aladadyan, Administrator		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff did not follow proper COVID-19 infection control guidance at the facility on several occasions.

INVESTIGATION FINDINGS:

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At 9:30am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate the allegation above. LPA was greeted by Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit.

Upon arrival LPA observed S1 was not wearing a mask and LPA was not screened for an infection control. LPA asked S1 to wear the mask and S1 immediately complied.

From approximately 9:45am-10:15am, LPA conducted a physical plant tour of the facility and interviewed S1 and the Administrator.

Interviews with the Administrator and S1 confirmed that sometime, around January 2022, a random visit was made by a credible witness who observed facility staff were not wearing masks. Although, the facility has a
Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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-20221109141505

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING SENIOR CARE, INC	FACILITY NUMBER: 197609860
	VISIT DATE: 11/16/2022

NARRATIVE

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"Mask Required" policy, Administrator admitted that sometimes S1 doesn't wear the mask when helping the residents. Administrator informed LPA that a meeting will be conducted with all staff regarding InfectionControl Guidance promptly. Based on an interview conducted with the Administrator and LPA observation this allegation is substantiated at this time.

Deficiencies were issued per CA code of Regulations Title 22 on LIC9099-D with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20221109141505

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING SENIOR CARE, INC	FACILITY NUMBER: 197609860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2022 Section Cited CCR 87470(c)(1)(F)	1 2 3 4 5 6 7	87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to provide in house training with all staff regarding Infection Control Requirements and COVID Protocol. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 11/17/22.
	8 9 10 11 12 13 14	Based on an interview with the Administrator, the licensee/administrator stated that during a previous visit conducted by the credible witness, staff did not comply with the section cited above by not wearing masks, which poses and immediate Health and Safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
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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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

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