197609877-5-23-2024-31-AS-NMAN-D5SU38-20240531151306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609877
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:37:31 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
04/10/2024 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20240410095157

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:	03:45 PM

ALLEGATION(S):

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Staff did not prevent resident from eloping from facility

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 did not prevent resident from eloping from facility

It was alleged that Staff did not prevent resident from eloping from facility. To investigate this allegation, during initial visit on 03/06/2023, LPA Smith interviewed the administrator, staff and requested documents relevant to the investigation from approximately 12:45 pm am to 2:10 pm. Resident # 1(R1) is no longer at the facility. Interviews with the administrator reveal Resident #1 (R1) did not elope from the facility. Administrator notes that all windows, and doors of the facility have alarms that chime when they are

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-20240410095157

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)

opened and there are cameras around the facility that also record activity on the facility and no residents have been recorded leaving the facility.

Three (3) of three (3) staff reveal will they respond immediately when any chime sounds within the facility. They immediately check inside and outside the facility including all cameras. LPA Smith checked the facility windows, and doors, and observed all sensors to be active and chimed audibly when opened. Chimes were also rechecked during today's visit and can be heard through out the facility.

Based interviews and observation 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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