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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609877
Report Date: 06/10/2024
Date Signed: 06/10/2024 03:20:44 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
04/05/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230405164319
FACILITY NAME:IN HOME CARE CENTERFACILITY NUMBER:
197609877
ADMINISTRATOR:DOVLATYAN, KRISTINEFACILITY TYPE:
740
ADDRESS:9023 GAVIOTA AVETELEPHONE:
(747) 998-7577
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 4DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kristine Dovlatyan
TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident sustained multiple pressure injuries while in care
Staff do not have accurate records for a resident
Staff did not abide to the admission agreement
INVESTIGATION FINDINGS:
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Licensing program analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to deliver findings. The administrator was contacted and arrived later. LPA Smith met with the administrator and disclosed the purpose of the visit.

During the initial visit on 04/06/24, LPA Jose Gary Tan conducted physical plant tour at 9:15 AM, requested copy of facility documents relevant to the investigation at 9:43 AM and interviewed staff and resident between 9:45 AM to 11:30 AM. On 01/16/24, LPA Tihesha Smith conducted a subsequent visit and interviewed four (04) residents, four (04) staff and reviewed records from 10:50 am – 1:05 pm. Resident #1 (R1) is no longer a resident at the facility and Resident # 6 (R6) unable to speak due to condition.

Resident sustained multiple pressure injuries while in care
It was alleged that facility resident #1 (R1) sustained multiple skin injuries causing extreme discomfort.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
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-20230405164319
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: 06/10/2024
NARRATIVE
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(cont. from 9099)

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. Staff denied being neglectful in R1’s care. Interviews revealed that R1 was admitted to the facility with red blisters all over their body. Resident was admitted to the facility with assigned hospice services. Although the Administrator was informed that the red blisters on R1’s body are not infected and will not transfer to others, the Administrator sent R1 to the hospital. R1 returned to the facility within 2 hours per discharge records and R1 had a chronic condition: “adult rush” requiring daily treatment. The Administrator stated that R1 was in the facility for one (1) week and within that week due to discomfort, R1 went to the hospital 3 times. On 03/28/23, R’s condition was discussed with the discharge nurse at the hospital and the decision was made to transfer R1 to a Skilled Nursing Facility.

A review of the facility records verified the information revealed by the staff. There was no information or evidence available during this investigation to conclude that R1 sustained multiple pressure injuries due to neglect. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time.

Staff did not have accurate records for resident.

It was alleged that staff did not have accurate records for residents. Interview with the administrator revealed
that she had all required documents for each resident. A review of the records including R1’s facility file, revealed that although the files were not organized, all required documents were present in folders designated for each resident. Due to no information available to support the allegation, therefore, based on observation and record review the allegation is UNSUBSTANTIATED at this time.

Staff did not abide to the admission agreement

It was alleged that credible witness observed lack of appropriate admission and discharge documentation.

(Cont to 9099C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
04/05/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230405164319

FACILITY NAME:IN HOME CARE CENTERFACILITY NUMBER:
197609877
ADMINISTRATOR:DOVLATYAN, KRISTINEFACILITY TYPE:
740
ADDRESS:9023 GAVIOTA AVETELEPHONE:
(747) 998-7577
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 4DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kristine Dovlatyan
TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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2
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5
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7
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9
Staff did not properly safeguard the residents’ medications
Resident's admission agreement has been forged while in care

INVESTIGATION FINDINGS:
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Licensing program analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to deliver findings. The administrator was contacted and arrived later. LPA Smith met with the administrator and disclosed the purpose of the visit.

During the initial visit on 04/06/24, LPA Jose Gary Tan conducted physical plant tour at 9:15 AM, requested copy of facility documents relevant to the investigation at 9:43 AM and interviewed staff and resident between 9:45 AM to 11:30 AM. On 01/16/24, LPA Tihesha Smith conducted a subsequent visit and interviewed four (04) residents, four (04) staff and reviewed records from 10:50 am – 1:05 pm. Resident #1 (R1) is no longer a resident at the facility and Resident # 6 (R6) unable to speak due to condition.

Staff did not properly safeguard the residents’ medications
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20230405164319
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: 06/10/2024
NARRATIVE
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(cont from 9099A)

Staff did not properly safeguard the residents’ medications

It was observed that staff #1 (S1) pull out R1’s medication from the unlocked closet in R1’s room to assist R1. At the time of this visit at 2:30pm LPM Margaryan interview S1 in Armenian and she verified the information alleged by the complainant. LPM Margaryan also inspected R1’s room and S1 was able to show a storage space where she was and is currently keeping peroxide solution for R1. Based on interview and observation there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Resident's admission agreement has been forged while in care

It was alleged that Resident's admission agreement has been forged while in care. A credible witness observed that the dates on R1’s admission agreement were forged. A review of R1’s admission agreement verified the allegation. There was information or evidence available during this investigation to conclude that Resident's admission agreement has been forged while in care therefore, based on record review and credible witness, the allegation is SUBSTANTIATED at this time.

Deficiencies cited on 9099D

Exit inteview conducted/copy of report given.






SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20230405164319
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2024
Section Cited
CCR
87465(h)(1)(B)
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Incidental Medical and Dental Care.
(h) (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed
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See Correction below
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This requirement was not met based on observation and interviews medication was not properly stored which posed a health and safety risked for residents in care.
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The licensee moved the perixode on day of visit: 05/23/24
Type B
05/23/2024
Section Cited
CCR
87506(a)
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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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The licensee will provide a written statement of understanding of how documents should be corrected or updated moving forward. POC date:06/20/24
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This requirement was not met based on observation and interviews that dates on files were overwriten/crossed out which posed a potential health and safety risk to residents 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20230405164319
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: 06/10/2024
NARRATIVE
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12
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15
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32
(Cont from 9099C)

The Administrator stated that she always keeps appropriate documents for all resident’s admission and discharge.She indicated that she is not only keeping admission and discharge records from the facility but also from the hospital and following doctors’ instructions and following all items outlined in the admissions agreements. A review of facility records verified the information received from the Administrator. Due to no information available to support the allegation, therefore, based on observation and record review the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted/Copy of report given.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6