197609862-8-31-2021-31-AS-NMAN-C8WVPU-20211119153720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609862
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:28:54 PM

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
08/25/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210825154020

FACILITY NAME:	EMERALD ESTATE SENIOR CARE, INC		FACILITY NUMBER:	197609862
ADMINISTRATOR:	LYSENKO, OLENA		FACILITY TYPE:	740
ADDRESS:	10401 ENCINO AVE		TELEPHONE:	(747) 300-2232
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	08/31/2021
		UNANNOUNCED	TIME BEGAN:	08:14 AM
MET WITH:	Vicky Harapetyan - Assistant Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident did not receive a safe and proper discharge from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit to this facility to investigate the above allegation. LPA met with Assistant Administrator Vicky Harapetyan and explained the reason for the visit.

LPA conducted physical plant tour at around 8:58 AM. Requested facility documents relevant to the investigation at 9:40 AM and interviewed staff and residents between 10:00 AM to 1:30 PM. LPA record review revealed that Resident #1 (R1) was self responsible, signed own check to pay, facility admission agreement and Home Health admission agreement. LPA's interview with the staff between 10:00 AM and 1:30 PM, revealed that R1 seemed to be unhappy and aggressive towards staff. LPA's interview with the administrator at 12:30 PM, revealed that she offered to assist R1 for another placement if R1 was unhappy and wanted to leave but R1 chose to go a lady who offered an inexpensive place to live. R1 left the facility voluntarily on 01/10/2021.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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-20210825154020

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: EMERALD ESTATE SENIOR CARE, INC	FACILITY NUMBER: 197609862
	VISIT DATE: 08/31/2021

NARRATIVE

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(continued from LIC 9099)

Further interview with administrator also revealed that R1 was given an emergency packet, consisted of CA Driver's License, medication list, Insurance information, Identification and Emergency Information (LIC 601) and Physician Orders for Life Sustaining Treatment (POLST) when R1 left the facility. LPA interview with Staff #1 (S1) at 10:20 AM revealed that S1 assisted R1 pack own belongings including R1's medication.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

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