197609891-6-28-2021-31-AS-NMAN-C93N9Z-20211124091647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609891
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:58:26 PM

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
06/16/2020 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20200616143655

FACILITY NAME:	ANGELES ASSISTED LIVING		FACILITY NUMBER:	197609891
ADMINISTRATOR:	ASATRYAN, YULIYA		FACILITY TYPE:	740
ADDRESS:	15942 BAHAMA STREET		TELEPHONE:	(818) 891-4183
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Yuliya Asatrayan, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not assisting resident with discharge planning
Facility did not report suspected abuse as required
Resident walked out of the facility unsupervised

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted subsequent complaint investigation for the above noted allegations. LPA met with Administrator Yuliya Asatryan. The purpose of the visit was discussed.
Facility is not assisting with discharge planning.
It was reported that the facility is not assisting resident #1 (R1) with discharge planning. To investigate the allegation, on 6/26/2020 at 2:10pm and on 9/4/2020 at 1:44pm LPA Valenzuela spoke with the Administrator who indicated that during the last few months, R1 was telling everyone that they wanted to go home. R1 has a house and wanted to move back home. However, due to R1's health conditions, the Administrator believed that R1 is unable to live on their own. The Administrator communicated with R1's family and they agreed that prior to discharge from the facility, R1 needed a full medical evaluation. Thus, R1 left before they could visit the doctor. On 9/4/2020 at 10:44am LPA spoke to R1's family and they verified the information provided by the Administrator. Therefore, the allegation is UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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 4

Control Number 31-AS-20200616143655

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: ANGELES ASSISTED LIVING	FACILITY NUMBER: 197609891
	VISIT DATE: 06/28/2021

NARRATIVE

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Facility did not report suspected abuse as required.
It was reported that the facility did not report suspected financial abuse as they are required to do as a mandated reporter. During the investigation on 9/4/2020 at 1:44pm LPA spoke to the Administrator regarding this issue. Administrator stated that they did report suspected financial abuse to Adult Protective Services (APS). In addition, the issue was discussed with the family and Administrator was informed that R1 misplaced the money which was later found and was deposited back to his bank account. LPA reviewed bank statements and verified what the Administrator said. In addition, on 6/22/2020 at 3:32pm LPA spoke with APS who affirmed that suspected financial abuse was reported by the Administrator, Based on interviews and record review, there is no sufficient information to support the allegation at this time. Therefore, the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/16/2020 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20200616143655

FACILITY NAME:	ANGELES ASSISTED LIVING		FACILITY NUMBER:	197609891
ADMINISTRATOR:	ASATRYAN, YULIYA		FACILITY TYPE:	740
ADDRESS:	15942 BAHAMA STREET		TELEPHONE:	(818) 891-4183
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS:	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Yuliya Asatrayan, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident walked out of the facility unsupervised

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted subsequent complaint investigation for the above noted allegation. LPA met with Yuliya Asatryan. The purpose of the visit was discussed.
It was alleged that on 6/12/2020, R1 walked out of the facility unsupervised and was missing for over an hour. He was found under a tree by the Administrator. R1 had left the facility unsupervised on a previous occasion. On 9/24/2020 at 1:44pm LPA spoke to the Administrator and she admitted that the incident occurred and that R1 did leave the facility unsupervised. On 6/12/2020 at 4:45pm LPA received R1's physician report and other documents for review. Records revealed that R1 is unable to leave the facility unassisted. The information revealed from the interviews and record review verifies the allegation. Therefore, the allegation is SUBSTANTIATED at this time.
Under Title 22; Division 6; Chapter 8, the following citations were issued and recorded on LIC9099D. No other health and safety hazards were noted during this visit.
Exit interview conducted. A copy of the report was issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20200616143655

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: ANGELES ASSISTED LIVING	FACILITY NUMBER: 197609891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/06/2021 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464(d) Basic Services (d)A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs and providing other basic services either directly or through outside resources.	1 2 3 4 5 6 7	The administrator will inform in writing how the Licensee is going to ensure that residents that are identified to be a risk for wandering will be supervised as required.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record review licensee did not properly supervise R1 as R1 was at risk for wandering and was left unattended. This poses an immediate health and safety risk to residents 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.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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