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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609889
Report Date: 11/05/2021
Date Signed: 11/05/2021 04:10:52 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
04/16/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210416135138
FACILITY NAME:PEARL OF WEST HILLS, INCFACILITY NUMBER:
197609889
ADMINISTRATOR:IRINA, KARBACHINSKIYFACILITY TYPE:
740
ADDRESS:23427 VICTORY BLVDTELEPHONE:
(818) 854-6306
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff hit resident
Staff caused injury to resident
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan.

In regard to the allegation it was reported that facility staff injured Resident 1 (R1) by hitting R1 in the eye resulting in severe bruising. These allegations were investigated by Lorraine Patterson, Investigator with Community Care Licensing Division’s Investigations Branch.

On 04/26/2021 Investigator Patterson conducted interviews with various individuals including the Licensee/Administrator Irina Karbachinsky, Resident 2 (R2), facility volunteer. Additionally, on 4/26/2021 Investigator attempted to interview Resident 1 (R1) but was unable to do so. On 5/20/2021 Investigator Patterson conducted interview with R1’s responsible party and hospice staff. The investigator attempted to interview the complainant but was unable to do so.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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-20210416135138
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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
VISIT DATE: 11/05/2021
NARRATIVE
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On 5/27/2021 Investigator conducted review of the Los Angeles Police Department (LAPD) Incident report which documented that the police were called to the facility for a welfare check. During the call officers spoke with licensee/administrator, hospice nurse, and R1’s responsible party. The LAPD report documented “The Reason and Cause of Injury as: Accident, Fall. The Extent of Injury: Minor”

Information obtained during the course of the investigation revealed the following: On 3/27/2021 R1 was very agitated at the facility. Due to the agitation resident was running around the facility and ran into the facilities closed sliding door hitting his/her face. After the incident Administrator contacted the hospice agency. Hospice nurse visited R1 and completed an assessment. Administrator also contacted R1’s responsible party/family to notify them of the incident.

Based on the lack of witnesses and evidence to corroborate the allegations Investigator Patterson has determined the allegations to be Unsubstantiated at this time.

Facility increased resident's rate without proper notice:

In regard to the allegation it was reported that the licensee/administrator increased Resident 1 (R1’s) fees several times after admission to the facility without providing proper notice. During the initial 10-day complaint visit which was conducted on 4/20/2021 LPA conducted interview with the administrator Irina Karbachinsky. When interviewed the Administrator denied raising R1’s monthly fees. On 10/17/2021 LPA conducted interview with R1’s responsible party/family who also denied that the R1’s fees were increased from the initial agreed upon rate. Based on the information obtained from the interviews conducted the allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to the administrator IRINA_KARBACHINSKIY@HOTMAIL.COM

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 6 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
04/16/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210416135138

FACILITY NAME:PEARL OF WEST HILLS, INCFACILITY NUMBER:
197609889
ADMINISTRATOR:IRINA, KARBACHINSKIYFACILITY TYPE:
740
ADDRESS:23427 VICTORY BLVDTELEPHONE:
(818) 854-6306
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff is over medicating resident
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan.

During the initial 10-day complaint visit conducted on 4/20/2021 LPA requested to review medications for resident 1 (R1). During the review LPA photographed the medications as provided by the licensee/administrator. LPA requested to review the centrally stored medication and destruction log for R1 which the licensee did not complete. During the visit LPA obtained copies of pertinent documents for R1 including but not limited to West Hills Hospital records, list of medications. When speaking with the administrator LPA requested for a completed Centrally Stored Medication Destruction records (CSMDR) and hospice records to be submitted. The requested documents were faxed on 4/27/2021.

The hospital records reviewed revealed the following: Upon hospitalization on 04/15/2021 caregiver reported to the hospital that resident 1 (R1) required multiple PRN medications to remain calm “which may often be too sedating.” At the hospital staff reported that R1 was given several medications Geodon, Ativan, Seroquel and Depakote.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20210416135138
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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
VISIT DATE: 11/05/2021
NARRATIVE
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On 10/17/2021 LPA conducted review of the submitted CSMDR, hospice medication list for March and April 2021. Records reviewed revealed that R1 does not have a prescription for Geodon, and the medication is not listed/documented in facility, hospital, hospice records or any of the submitted/reviewed records. Additionally, LPA conducted medication count utilizing the photos taken of the medications in bubble packs on 4/20/2021. LPA also used the information provided by the licensee such as the start dates, hospitalization dates and the order dates listed on the hospice records. Medication count revealed the following: R1’s medications were not assisted with as prescribed. R1 was given additional doses of various medications. (7 extra pills of temazepam, 4 extra pills of melatonin, 25 (21 and 4) extra pills of Quetiapine/Seroquel from 2 different prescriptions. During the 4/20/2021 visit the administrator did not provide the medication Lorazepam/Ativan for LPA to review. The medication was also not listed in the March 2021 CSMDR. Medication documentation reviewed also revealed inconsistencies with the hospice medication list, licensees CSMDR and the medication orders on the bubble packs.

Based on the medications counted and records reviewed the allegation is Substantiated.

Exit interview conducted, copy of report citations and appeal rights emailed to the administrator IRINA_KARBACHINSKIY@HOTMAIL.COM

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20210416135138
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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited
CCR
87465(C3)(D3)
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If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the
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immediate health, safety and personal rights risk to R1.
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resident's record. The record shall include the date & time the PRN medication was taken, the dosage taken, & the resident's response.
This requirement was not met as evidenced by: Based on records review and interview the licensee did not comply with the cited sections by not documenting when PRN medications were administered to R1. Which posed an
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Licensee/Administrator will schedule vendorized medication training for all staff. Training will need to be scheduled within 24 hours and completed by 11/19/2021
Type A
11/08/2021
Section Cited
CCR
87465(c)(2)
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(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided the following requirements are met: (2) Once ordered by the
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Licensee/Administrator will schedule vendorized medication training for all staff. Training will need to be scheduled within 24 hours and completed by 11/19/2021
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physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on medication review the licensee did not comply with the cited sections by not giving medications per the physicians directions which posed an immediate health, safety and personal rights risk to R1.
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Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20210416135138
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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited
CCR
87465(e)
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(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
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Licensee/Administrator will schedule vendorized medication training for all staff. Training will need to be scheduled within 24 hours and completed by 11/19/2021
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This requirement was not met as evidenced by: Based on hospital records review the licensee did not comply with the section cited above by not having a signed written order from a physician for the medication Geodon given to resident 1 which posed an immediate health, safety and personal rights risk to R1.
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Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency.
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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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6