197609877-4-3-2024-31-AS-NMAN-D4TSEV-20240430134923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609877
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:36:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
03/26/2024 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20240326144618

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:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Kristine Dovlatyan		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to neglect, resident was dehydrated

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 9:50 a.m. on 04/03/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, initial complaint visit. LPA met with Staff #1 (S1) and later the administrator and disclosed the reason for the visit.

Regarding the allegation “Due to neglect, resident was dehydrated” it as alleged Resident #1 (R1) was neglected and not provided adequate hydration. To investigate the allegation, LPA toured the facility at 10:00 a.m. today, conducted a file review of pertinent records at 10:30 a.m. including but not limited to the staff list, resident list, medical assessment, and care notes, and interviewed the administrator, two (02) staff, a nurse, and one (01) out of four (04) residents between 11:00 a.m. and 12:30 p.m.

Interview with the administrator at 11:00 a.m. today revealed R1 often refused bathing, grooming, and feeding support. Staff called 9-1-1 for R1 on 03/24/2024 due to low blood pressure and malnourishment.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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 2

Control Number 31-AS-20240326144618

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IN HOME CARE CENTER	FACILITY NUMBER: 197609877
	VISIT DATE: 04/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interview with Staff #2 (S2) at 11:30 a.m. today revealed R1 refused staff attempts to feed and provide fluids to R1 on 03/23/2024. Staff reminded R1 of the importance to eat and drink fluids. Staff provided a variety of options for R1, but R1 only drank a little juice and ate no food. Interview with Resident #2 (R2) at 12:00 p.m. today revealed staff provide sufficient care and supervision to the residents in the facility. Interview with a hospital nurse at 12:30 p.m. today revealed R1 suffered from confusion and would not accept food or fluids, so a feeding tube was provided. Record review confirmed R1 had a history of refusing care at the facility. Based on interviews and record review, staff provided adequate care and supervision, and R1 refused care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety risks were observed.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2