197609864-8-18-2022-29-AS-DPEA-CJPUDJ-20220928152936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609864
Report Date: 08/18/2022
Date Signed: 08/18/2022 11:19:19 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20220811082941

FACILITY NAME:	GRANT SERENITY HOMES OF SF VALLEY, INC		FACILITY NUMBER:	197609864
ADMINISTRATOR:	ADJIAN, MARTIN		FACILITY TYPE:	740
ADDRESS:	6928 PEACH AVE		TELEPHONE:	(818) 425-6797
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	08/18/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nvard Gevorkian - Licensee		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility is not following COVID -19 masking requirements.

Facility is not screening visitors for COVID -19.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint investigation for the allegations listed above. Upon arrival LPA met with Nvard Gevorkian and explained the reason for the visit.
At approximately 9:30am, LPA conducted physical plant, interviewed staff and residents as well as reviewed and obtained copies of pertinent documents relevant to the investigation.

It was alleged that facility is not following COVID-19 masking requirements. Regional office received information from a credible witness that while visiting the facility, they observed that some caregivers were not wearing masks. Upon arrival to the facility, LPA observed all staff wearing masks. However, LPA nterview with the licensee and Staff 1 (S1) revealed they recently had a visit from an outside agency who observed S1 not wearing a mask while working with the residents. Based on interviews, the allegation of "Facility is not following COVID-19 masking requirements is deemed SUBSTANTIATED at this time.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

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 29-AS-20220811082941

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANT SERENITY HOMES OF SF VALLEY, INC	FACILITY NUMBER: 197609864
	VISIT DATE: 08/18/2022

NARRATIVE

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Continued from 9099

It was further alleged that facility is not following COVID-19 screening protocols. Upon entering the facility, the LPA was screened at the door and temperatures were taken by Staff. Additionally, LPA’s observed a Home Health nurse coming into the facility at approximately 9:45am. LPA record review revealed that the Home Health nurse had not signed into the visitor’s log showing that they had been screened for COVID-19. During staff interviews, staff reported that they were busy and had forgotten to have nurse sign in. Based on interviews and record review, the allegation of “facility is not following COVID-19 screening protocols” is deemed Substantiated at this time.

Citations Issued. See LIC 9099D. Appeal Rights discussed. Exit interview conducted and copy of the report emailed to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220811082941

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANT SERENITY HOMES OF SF VALLEY, INC	FACILITY NUMBER: 197609864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/19/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agreed to advised staff on wearing masks at all times inside the faciltiy and conduct a training on CA Dept of Public Health Guidance for the use of face coverings and COVID-19 screening protocols and submit proof to LPA via email by end of day 8/19/2022.
	8 9 10 11 12 13 14	Based observations and interviews, the Licensee did not ensure the personal rights of persons in care to live in a safe, healthy, and comfortable home as staff did not wear face coverings at all times while inside the facility and did not follow COVID-19 infection screening protocol, which poses an immediate health and safety risk to residents in care	8 9 10 11 12 13 14
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	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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC9099 (FAS) - (06/04)

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