197609877-1-16-2024-31-AS-NMAN-D5SQAJ-20240531115959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609877
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:36:30 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
02/27/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230227123033

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: 5	DATE:	01/16/2024
		UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Kristine Dovlatyan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not ensure a resident was properly fed while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with the administrator Kristine Dovlatyan and disclosed the purpose of the visit.
During initial visit, on 03/06/2023, LPA Smith conducted a physical plant tour, interviewed the administrator, and obtained and requested copies of documents relevant to the investigation.

Staff did not ensure a resident was properly fed while in care
It was alleged that Resident #1 (R1) was not being fed. To investigate this allegation, LPA Smith conducted a physical plant tour at 10:40, interviewed four (04) residents, four (04) staff and reviewed records from 10:50 am – 1:05 pm. (R1) is no longer a resident at the facility and LPA unable to reach for an interview. Resident # 6 (R6) unable to speak due to condition.

During interviews LPA observed lunch meal being prepared and staff informing residents lunch is being

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: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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-20230227123033

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: 01/16/2024

NARRATIVE

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(cont from 9099)

served. Interviews with four (4) out of four (4) staff revealed three (3) meals are served with a snack served in between meals. Two (2) out of two (2) staff reveal residents may refuse meal but a plate is always served. Interview with four (4) out of four (4) residents revealed received all meals when present at the facility.

Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is 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: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC9099 (FAS) - (06/04)

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