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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609860
Report Date: 02/21/2024
Date Signed: 02/21/2024 10:09:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/05/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240205143554
FACILITY NAME:AMAZING SENIOR CARE, INCFACILITY NUMBER:
197609860
ADMINISTRATOR:ANNA PETROSYANFACILITY TYPE:
740
ADDRESS:16938 CITRONIA STREETTELEPHONE:
(818) 853-6695
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Yelena Aladadyan- AdministratorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff are unable to communicate with residents.
Staff do not ensure residents are served food of good quality.
INVESTIGATION FINDINGS:
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On 02.21.2024 License Program Manager (LPM) Nichelle Gillyard and Licensing Program Analysts (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Staff #1 (S1) who granted access. S1 contacted the administrator Yelena Aladadyan (S2) to advised that LPA was at the facility. Administrator arrived at 9:28 AM, LPA explained the purpose of the visit.

At 9:10 AM LPM and LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation #1: Staff are unable to communicate with residents.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
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 6
Control Number 31-AS-20240205143554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860
VISIT DATE: 02/21/2024
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit. Regarding the allegation above it is alleged that facility staff are unable to communicate with residents due to a language barrier. On 02-14-2024 LPAs investigated this complaint.

LPAs conducted interviews and concluded that the one and only staff on duty at the time of this investigation was unable to effectively communicate with the residents of which the majority speak English. Staff used a translator to attempt to communicate. Staff was unable to effectively communicate on how to address an emergency should one happen. Staff on duty was unable to effectively communicate in English. At 9:30 AM LPA initiated interviews with six(6) residents. Four (4) out of six (6) residents have trouble communicating with staff for their basic needs. LPA then asked a series of questions to S1 regarding basic needs and care for the residents. S1 was confused, unable to respond or answer any of the questions. This complaint allegation, Staff are unable to communicate with residents is substantiated.

Allegation #2: Staff do not ensure residents are served food of good quality.

To investigate this allegation, License Program Analyst (LPA) Leslie Ngo-Castaneda conducted toured the home, observed food service, conducted file reviews, and interviewed residents at 9:38AM. LPA observed there to be 2 days of non-perishable and one week of perishable foods. Foods observed were high is sodium and sugar. Foods included frozen pizza, mini-sausages, pizza, cans of soup canned corn, canned peas, pasta and Sunny D. LPAs observed minimal fresh fruit and or vegetables. LPAs reviewed resident’s records and per the resident’s physicians reports 6 out of 6 resident are on modified diets.

LPA interviewed four (4) out of six (6) residents who stated the LPAs that the facility does not provide fresh food and the food is mostly canned with too much salt. Residents gave sample of food that was serve: microwaved soggy pizza that is un-edible, canned corn/ peas, or spaghetti with ketchup. During the visit, LPA observed canned chicken noodle soup, mini-sausages, untoasted one (1) slice of white bread smeared with butter, and bottled sunny-d orange juice was served for lunch.

Moreover, an interview with staff confirmed that the facility does not follow the sample food menu posted in the kitchen to provide quality food to the residents. LPA requested staff training regarding food service and modified diets. There was no training.

Based on the information gathered, there is sufficient evidence to conclude allegation is substantiated. Exit interview conducted. Copy of this report issued

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20240205143554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2024
Section Cited
CCR
87411(d)(3)
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Personnel Requirements - General
(d) (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
This requirement is not met as evidenced by:
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Facility will have to train and ensure staff to have staff to properly comnunicate with the residents. This will be submitted to regional by 3.6.2024
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Based on an interview with the Administrator, during a previous visit conducted by the staff did not comply with the section cited above by not having staff that could communicate with residents, which poses and immediate Health and Safety and personal rights risk to persons in care.
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Type B
02/21/2024
Section Cited
CCR
87555(a)
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General Food Service Requirements: The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected
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Facility will need to have a new menu available for residents for breakfast, lunch, snacks and dinner. This will be submitted to regional office by: 3.6.2024
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stored, prepared, and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on observation facility did not served healthy food to the residents, which poses and immediate Health & Safety and personal rights risk to persons in care.
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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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20240205143554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2024
Section Cited
CCR
87411(d)(1)
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All personnel shall be given on the job training or have related experience in the job assigned to them. This training/ related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job
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Facility will need to have a new menu available for residents for breakfast, lunch, snacks and dinner. This will be submitted to regional office by: 3.6.2024.
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 performance:
(1) Principles of good nutrition, good food preparation and storage, and menu planning.
This requirement is not met as evidenced by:
Facility was serving canned and frozen food.
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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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/05/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240205143554

FACILITY NAME:AMAZING SENIOR CARE, INCFACILITY NUMBER:
197609860
ADMINISTRATOR:ANNA PETROSYANFACILITY TYPE:
740
ADDRESS:16938 CITRONIA STREETTELEPHONE:
(818) 853-6695
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Yelena Aladadyan- AdministratorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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2
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Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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On 02.21.2024 License Program Manager (LPM) Nichelle Gillyard and Licensing Program Analysts (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPM & LPA was greeted by Staff #1 (S1) who granted access. S1 contacted the administrator Yelena Aladadyan (S2) to advised that LPA was at the facility. Administrator arrived at 9:28 AM, LPA explained the purpose of the visit.

At 9:10AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation #1: Staff mishandling resident medication.

It was alleged staff have not given and misplaced resident #1 (R1) medication.

Continue to LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20240205143554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860
VISIT DATE: 02/21/2024
NARRATIVE
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 To investigate the allegation License Program Analysts (LPAs) Leslie Ngo-Castaneda & Perchui Khurshudyan conducted an initial visit on 02.14.2024. LPAs reviewed six (6) out of six (6) Centrally Stored Medication and Destruction Records (CSMDR).

Records indicated the name and quantity of medication when R1 arrived at facility on 1.29.2024, this is then accounted for during LPAs visit. Base on LPA observation, medication was accounted for all the residents on CSMDR and medication in the facility. Based on medication records, interviews and observation, there is not enough evidence that medications were not given or misplaced. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted and copy of report given to administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6