197609877-6-14-2021-31-AS-EMIR-CCMSPS-20220318140336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609877
Report Date: 06/14/2021
Date Signed: 06/14/2021 04:46:37 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
05/20/2020 and conducted by Evaluator Martina Berry

COMPLAINT CONTROL NUMBER: 31-AS-20200520140125

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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9

Staff did not allow resident to return to facility

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.

To investigate the above allegation, the LPA conducted an inital complaint visit on 5/21/2020. The LPA reviewed resident records on 10/8/2020 and interviews on . According to records, R1 requested to leave the facility on 5/9/20. It was documented that R1 was hospitalized due to health reasons on the same day. According to an interview with the facility administrator on 06/03/2020, R1 returned to the facility from the . File review conducted on 10/8/2020 confirmed this information. Based on information obtained from 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.

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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