<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609889
Report Date: 02/06/2023
Date Signed: 03/06/2023 03:00:46 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
02/03/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230203150413
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:
02/06/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Olga KnyazevaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not properly assist in feeding resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is to amend the report that was delivered on 02/06/2023.
Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA arrived at 1:30 PM. Upon entry, LPA met with the caregiver,Olga Knyazeva and explained the reason for the visit. Olga Knyazeva was degnated by the administrator, Irina Karbachinskiy, to sign and accept this report.

--- Facility staff did not properly assist in feeding resident.
It was alleged that staff are putting food into the resident’s mouth despite it running out of their mouth. To investigate this allegation, on 02/06/2023, LPA interviewed the Administrator at around 2:00 PM, requested pertinent documents at 2:45 PM and interviewed other parties at 3:15 PM. During interviews with the Administrator, they stated that Resident #1 (R1) has difficulty swallowing, needs prompts to swallow and at times forgets that there is food in their mouth.
(Cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
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 3
Control Number 31-AS-20230203150413
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: 02/06/2023
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
Administrator also stated that they do not feed R1 while they have food in their mouth and that staff do not have client specific training regarding feeding assistance and aspiration pneumonia or any recent training by an agency. During record reviews, LPA discovered that R1 needs feeding assistance due to health conditions. Record review also revealed that staff do not have client specific training regarding feeding assistance and aspiration pneumonia. During interview with other parties, they stated that R1 was being fed while food was running down the side of R1's mouth.

Based on interviews and record review, there is sufficient corroborating information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230203150413
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: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2023
Section Cited
CCR
87411(c)(3)(B)
1
2
3
4
5
6
7
Personnel Requirements - General (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health & Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following: Importance
1
2
3
4
5
6
7
Administrator will ensure that all staff get client specific training for feeding assistance and aspiration pneumonia by the POC due date.
8
9
10
11
12
13
14
 and techniques of personal care services, including but not limited to,..feeding...This requirement is not met as evidenced by; Based on interviews & record review, staff do not have client specific training for feeding assistance & aspiration pneumonia which poses an immediate health, safety and personal rights risk to resident in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3