197609877-6-14-2021-31-AS-NMAN-C7CSLN-20210930135836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609877
Report Date: 06/14/2021
Date Signed: 06/14/2021 04:48:34 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
04/24/2020 and conducted by Evaluator Martina Berry

COMPLAINT CONTROL NUMBER: 31-AS-20200424124234

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; 6	CENSUS: 5	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Kristine Dovlatyan		TIME COMPLETED:	03:06 PM

ALLEGATION(S):

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1. Staff unable to communicate with resident due to language barrier.

2. Resident did not receive medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martina Berry conducted a subsequent complaint visit to investigate the above allegations. The LPA met with staff Marine Kolyan and spoke with Administrator Kristine Dovlatyan by phone to conduct an entrance interview. The Administrator later arrived at the facility to assist the LPA.

Allegation #1 Staff unable to communicate with resident due to language barrier.
To investigate this allegation, the LPA conducted interviews with staff on 5/1/20, 5/21/20, 1/15/2021, and 6/14/2021. During interviews, staff were able to communicate with the LPA. Although some staff required assistance to communicate on some interview questions, other staff members were available to assist. During the facility visit on 6/14/21, the LPA observed that S1 required assistance to speak with the LPA, however S1 was able to communicate with residents using short phrases, words, and gestures. According to Title 22 Regulations, staff must be able to communicate with residents, but are not required to speak the resident’s language. Based on staff interviews and Title 22 Regulations, this allegation is unsubstantiated.
(continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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-20200424124234

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: 06/14/2021

NARRATIVE

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Allegation #2 Resident did not receive medication as prescribed.

To investigate this allegation, the LPA conducted an initial complaint visit on 5/1/20. The LPA reviewed review records for R1 on 10/7/20. According file review, all medications were given as prescribed. The LPA interviewed the administrator on 5/1/20 about medication administration. According to staff interview, missed medication are documented and consultation is completed with the resident’s doctor. Resident records reflected missed medication documentation. Based on interviews and file review, this allegation is unsubstantiated.

No deficiencies cited. The LPA conducted an exit interview with Administrator Kristine Dovlatyan. A copy of this report was provided to the Administrator via email.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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