197609877-5-23-2024-31-AS-NMAN-D5SQAH-20240531115959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609877
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:27:19 PM

Unsubstantiated

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
02/27/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230227123033

FACILITY NAME:	IN HOME CARE CENTER		FACILITY NUMBER:	197609877
ADMINISTRATOR:	DOVLATYAN, KRISTINE		FACILITY TYPE:	740
ADDRESS:	9023 GAVIOTA AVE		TELEPHONE:	(747) 998-7577
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 4	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Kristine Dovlatyan		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff neglect resulted in a resident to be hospitalized while in care
Staff did not properly report an incident involving a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith and Naira Margaryan conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation on 05/23/2024. The administrator was contacted and arrived later. Licensing staff met with the administrator Kristine Dovlatyan and disclosed the purpose of the visit.

Staff neglect resulted in a resident to be hospitalized while in care

It was alleged that staff neglect resulted in a resident to be hospitalized while in care. To investigate this allegation, during initial visit on 03/06/2023, LPA Smith conducted a physical plant tour, interviewed the administrator, and obtained and requested copies of documents relevant to the investigation. Interview with the administrator revealed that on 01/21/2023 by recommendation from Resident #1 (R1) doctor, R1 was taken to the hospital by the administrator due to weakness, dark urine and odor. Administrator drove R1 to the hospital in personal vehicle and R1 was able to ambulate to the car and get in without

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20230227123033

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: IN HOME CARE CENTER	FACILITY NUMBER: 197609877
	VISIT DATE: 05/23/2024

NARRATIVE

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(Cont from 9099)

assistance. The administrator was instructed by the doctor to contact them upon arrival. Administrator disclosed that R1 was admitted to the hospital after she took him there. Administrator also revealed followed up with hospital, but hospital staff only disclosed that since R1 would not be returning to the facility they will not provide any information regarding the status of R1.

Based interview although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Staff did not properly report an incident involving a resident

It was alleged that staff did not properly report an incident involving a resident. Review of records on 03/06/23 reveal that incident reports are faxed within required timeframe and a copy of the incident report form is kept in resident records. Interview with administrator revealed resident’s responsible parties are contacted, licensing notified (and additional agencies if any).

Based interviews and record review although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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