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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609889
Report Date: 01/19/2022
Date Signed: 01/19/2022 05:28:24 PM

Substantiated


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
11/09/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20211109140750
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: 3DATE:
01/19/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff restricting resident from having phone calls
Staff are mismanaging resident's medication


INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with ---- and informed her the purpose of the visit.

Regarding the allegation of Staff restricting resident from having phone calls it was reported that families are able to speak with the residents only by calling the phone number of the Licensee Irina Karbachinskiy. It was also reported that the administrator would not allow resident 1 (R1) to have phone calls with family members in private. An initial 10 day complaint visit was conducted on 11/17/2021. During the visit interview was held with the licensee who confirmed that they no longer have a facility phone line and when anyone wants to speak with a resident they will call her on her cell phone. When asked licensee also stated that she was very particular with R1 and would be present during phone calls. During the 11/17/2021 LPA informed the administrator that per title 22 regulations all facilities are required to have telephone service on the premises at all times. LPA also informed the administrator that she is violating the residents personal rights by not allowing them to make and receive personal/confidential calls.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
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 4
Control Number 31-AS-20211109140750
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: 01/19/2022
NARRATIVE
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The licensee informed the LPA that she would disconnect the telephone line from the facility fax to ensure that they have telephone services at all times. On 12/3/2021 LPA spoke with the licensee regarding her pending plan of corrections. During that phone call LPA was informed that the licensee was continuing to use the phone number for the fax. on 12/6/2021 at 2:05 pm LPA called the facility phone number, which kept ringing. LPA called again at 2:07 pm at which time the fax line was connected. On 1/18/2022 at 3:30 pm LPA called the facility phone number which kept ringing until the fax line was connected. Based on the interviews conducted and attempted phone calls made to the facility the department has obtained sufficient information to determine that the facility Staff are restricting resident from having phone calls therefore the allegation is Substantiated.

Regarding the allegation of Staff are mismanaging resident's medication it was reported that the licensee and staff are not ensuring residents medications are given as prescribed. An initial 10 day complaint visit was conducted on 11/17/2021 at which time LPA observed and documented as Licensee Irina Karbachinskiy counted medications for 2 residents. .Review of the medication records, and medication count revealed that
Licensee and/or staff mismanaged 6 or R1's medications by not ensuring they were given according to the physicians order. Review of the medications revealed that licensee had extra medications for 5 of the 6 medications and the 6 th medication Divalproex had run out without being refilled or discontinued by the physician. Licensee and/or staff also mismanaged medications for R2 by not ensuring that 4 medications were given according to the physicians order therefore the allegation is Substantiated.

Exit interview conducted, copy of report, citations, civil penalties and appeal rights issued and emailed to the licensee.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20211109140750
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: 01/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2022
Section Cited
CCR
87468.1(a)(14
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met as evidenced by:
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Licensee will review the cited regulation 87468.1. Licensee will submit a written statement that they have reviewed the regulation and indicate what steps will be taken to ensure the residents personal rights are not violated.
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Based on interview the licensee did not comply with the cited sections by allowing R1 to have personal/confidential phone calls with family which posed an immediate personal rightsviolation to R1.
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Type B
01/21/2022
Section Cited
CCR
87311
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 All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement was not met as evidenced by:
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Licensee will notify the department in writing what steps have been taken to correct this deficiency, Licensee and administrator will also submit a written statement that telephone services will be made available at the facility at all times.
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Based on interview and attempted telephone calls to the facility the licensee did not comply with the cited section by not ensuring that a telephone service is available on the premises at all times which poses an immediate personal rights violation to R1.
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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: 01/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20211109140750
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: 01/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2022
Section Cited
CCR
87465(a)(5)
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(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee and all staff attended vendorized medication training on 12/19/2021.

Licensee will submit a written statement notifying the department what steps will be taken to ensure residents are assisted with medications as prescribed.
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Based on medication count the licensee did not comply with the section cited by not assisting R1 and R2 with self administered medications as prescribed which posed/poses an immediate health and safety and personal right risk to residents in care.
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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: 01/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4