197609860-6-11-2023-31-AS-NMAN-CULPEL-20230811111518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609860
Report Date: 06/11/2023
Date Signed: 06/11/2023 05:23:34 PM

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
05/12/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230512145658

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:	06/11/2023
		UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Yelena Aladanyan, Co-Administrator		TIME COMPLETED:	05:32 PM

ALLEGATION(S):

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Staff does not ensure resident is provided clean drinking ware.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Yelena Aladanyan and explained the reason for the visit.

---Staff does not ensure resident is provided clean drinking ware.

It was alleged that straw seemed like it had mildew and water did not look clear. To investigate the allegation on 05/16/2023 LPA conducted physical plant tour at around 10:00 AM, interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During the physical plant tour LPA observed that Resident #1’s drinking cup and straw were not clean. During interviews with residents, R1 stated that the cup, straw and water are always clean.

(CONT. on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

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

Control Number 31-AS-20230512145658

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: 06/11/2023

NARRATIVE

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Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) all stated that they are given water in a plastic bottle, they do not use a straw and that both water and bottle are clean. LPA was unable to interview Resident #6 (R6). During interviews with staff, Staff #1 (S1) stated that if residents are using cups, the cup is washed after each use, a new straw is given with each new cup of water, and they only provide bottled drinking water.

Based on observation, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20230512145658

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: 06/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/14/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)…(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87468.1 Personal Rights of Residents in All Facilities; The written letter must be sent to the LPA by the POC due date.
	8 9 10 11 12 13 14	Based on observations, Resident #1 was not provided safe and healthful equipment as the cup and straw were not clean. This poses a potential health, safety and personal rights risk to residents in care.	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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

LIC9099 (FAS) - (06/04)

Page: 5 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230512145658

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:	06/11/2023
		UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Yelena Aladanyan, Co-Administrator		TIME COMPLETED:	05:32 PM

ALLEGATION(S):

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Staff does not ensure resident's hygiene needs are being met.
Staff are unable to communicate with residents due to language barrier.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Anna Petrosyan and explained the reason for the visit.

--- Staff does not ensure resident's hygiene needs are being met.

It was alleged that Resident #1 (R1) looked like ears had not been cleaned for some time and teeth were not brushed. To investigate the allegation on 05/16/2023 LPA conducted physical plant tour at around 10:00 AM, interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During the physical plant tour LPA observed that R1 was clean and well-groomed. During interviews with residents, R1 stated staff assist you with showering three times a week, staff follow the schedule and assist with washing face and brush teeth every morning.
(CONT. LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20230512145658

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: 06/11/2023

NARRATIVE

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Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) all stated that staff follow shower schedule and get assistance with all hygiene as needed. LPA was unable to interview Resident #6 (R6). During interviews with staff, Staff #1 (S1) stated all residents have a shower schedule, that R1 has third party assistance with showering and staff assist with washing R1’s face and brushing teeth every morning.

Based on observation and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff are unable to communicate with residents due to language barrier.

It was alleged that employee was not able to communicate because of a language barrier. To investigate the allegation on 05/16/2023 LPA interviewed staff at 11:30 AM and interviewed residents at 01:30 PM. During interviews with residents, R1, R2, R3, R4, and R5 all stated they can communicate with all staff and staff are able to meet all their needs. LPA was unable to interview Resident #6 (R6). During interviews with staff, S1 corroborated all residents’ statements, however, LPA was unable to interview Staff #2 (S2) in English as they did not understand the questions being asked.

Although LPA was unable to interview S2, all interviewed residents can communicate with S2, and all needs are being met. Based on interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2023

LIC9099 (FAS) - (06/04)

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