197609923-2-23-2022-29-AS-KHEN-CC52SG-20220301163905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609923
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:03:14 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20201105122427

FACILITY NAME:	BASSETT RESIDENTIAL CARE		FACILITY NUMBER:	197609923
ADMINISTRATOR:	TAVITIAN, HRIPSIME		FACILITY TYPE:	740
ADDRESS:	16017 BASSETT ST		TELEPHONE:	(818) 442-5702
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 5	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Emma Arutiunian		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Lack of care and supervision led to resident's death
Resident sustained multiple pressure injuries while in care
Facility staff did not assist resident with hygiene needs
Resident was left in soiled clothing for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Subsequent Complaint visit at 1:09PM for the purpose of delivering the findings of a complaint investigation conducted by the Department’s Investigation’s Branch (IB) Investigator Laura Garcia. LPA initially met with facility staff Rosana. House Manager Emma Arutiunian, who is authorized to sign reports, arrived at 1:35PM. Administrator Hripsime Tavitian was unavailable at the time of the visit. Entrance interview conducted.

On 11/06/2020, LPAs Kelly Dulek and Brian Balisi conducted an initial complaint inspection, during which, between 9:10AM and 10:45AM LPAs conducted interviews with the staff and residents and conducted a physical plant tour. LPAs also obtained copies documentation relevant to the investigation. IB Investigator Garcia then conducted interviews with facility staff, residents, and other relevant parties on the following dates: 12/08/2020, 12/17/2020, 01/26/2021, and 02/02/2021. Document review took place on the following dates: 11/10/2020, 11/18/2020, 01/27/2021, and 10/01/2021. During today's visit, LPA interviewed House
Report continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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 6

Control Number 29-AS-20201105122427

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT RESIDENTIAL CARE	FACILITY NUMBER: 197609923
	VISIT DATE: 02/23/2022

NARRATIVE

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Manager at 1:35PM and toured the facility at 1:53PM. The following was then determined:

Regarding the allegation: “Lack of care and supervision led to resident’s death:”

Resident #1 (R1) who was admitted to the facility on 09/30/2020, had previously resided at another licensed facility and had been under hospice care since 03/15/2020. Interviews revealed that during the three (3) days R1 resided at this facility, R1 was noted to be not eating well. On the morning of 10/03/2020, facility staff indicated R1 appeared to be weak, refusing meals, and having shortness of breath. R1’s hospice provider was contacted, arrived at the facility and called 9-1-1. The resident was then transported to the hospital, where R1 expired the same day. Record review revealed R1’s death was attributed to probable sepsis, chronic pressure wounds, and cardiovascular disease. Interviews confirmed R1 had a long history of self-neglect and the conditions surrounding R1’s passing were aligned with R1’s history of refusal regarding medical care. Medical professionals concurred that there was nothing suspicious or unexpected regarding R1’s expiration. Reports reviewed revealed there was no indication of any abuse or neglect by the facility staff. Based on interviews and records review, at this time there is insufficient evidence to support the allegation that “lack of care and supervision led to resident’s death.” Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Resident sustained multiple pressure injuries while in care:”

R1 was admitted to the facility on 09/30/2020 and had been under hospice care since 03/15/2020. Hospice admission documents, as well as facility admission paperwork, indicated the resident had pressure injuries on the sacro coccyx area (Stage IV) and on the buttocks area (Stage III), for which the Hospice agency was responsible for providing appropriate medical care. While the resident was noted to have decubitus sores on the face, interview and record review revealed the sores/marks were consistent with oxygen mask straps. Records confirm the hospice agency was administering oxygen to R1 while R1 was in care at the facility. Additionally, per the interviews with relevant medical professionals, R1 was diagnosed with “senile ecchymosis” – increased fragility to the skin due to aging on the side of R1’s face. Based on interview and record review, there is insufficient evidence to support the allegation at this time. Therefore, the allegation that “resident sustained multiple pressure injuries while in care” is deemed UNSUBSTANTIATED at this time.

Report continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20201105122427

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT RESIDENTIAL CARE	FACILITY NUMBER: 197609923
	VISIT DATE: 02/23/2022

NARRATIVE

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Regarding the allegation “Facility staff did not assist resident with hygiene needs:”

Interviews revealed facility staff assist residents with hygiene needs four (4) times a day for incontinent residents, or as needed based on resident request or staff observation. Two (2) of two (2) residents interviewed indicated they are changed frequently and staff regularly tend to any additional needs of the residents. While hospital records did indicate “the patient’s gown is soiled,” upon arrival to the Emergency Room, interviews did not reveal any additional information regarding the nature of the soiled gown. Emergency Medical Services (EMS) reports did not indicate a soiled gown or a concern with the resident’s hygiene. There is insufficient evidence to determine when the resident’s gown became soiled or whether the soiled gown was due to lack of hygiene care at the facility. Based on this information, although the allegation may be cause for concern, there is insufficient evidence to support the allegation. Therefore, the allegation that “Facility staff did not assist resident with hygiene needs” is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Resident was left in soiled clothing for an extended period of time:”

It shall be noted R1 was receiving hospice services for the entire duration of R1’s residency at this facility. Upon admission to the hospital, nurse notes indicated “the patient’s gown is soiled.” However, interviews revealed residents’ clothing is changed daily. Hospice nurse notes and hospice staff interview did not indicate details of the clothing change. Additionally, the hospice nurse indicated changing the resident’s clothing could either be completed by the facility staff or the hospice care staff. Facility staff indicated they had changed R1’s clothing daily during the 3 days R1 resided at the facility. Record review revealed that the hospice care plan lacked written information on specific duties for facility staff and hospice agency staff, including frequency and responsibility for changing residents clothing. Interviews with hospice staff did not reveal any detail into how long the resident was wearing specific clothing for or details of the alleged soiled clothing. During the facility tour on 11/06/2020, LPAs Balisi and Dulek observed each resident to have multiple clothing items available for use and all residents’ clothing was observed to be clean and regularly laundered. Based on interview, observation, and record review, although the allegation may have happened, at this time there is insufficient evidence to prove a violation occurred. Therefore, the allegation that “resident was left in soiled clothing for an extended period of time” is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted and a copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

Page: 3 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20201105122427

FACILITY NAME:	BASSETT RESIDENTIAL CARE		FACILITY NUMBER:	197609923
ADMINISTRATOR:	TAVITIAN, HRIPSIME		FACILITY TYPE:	740
ADDRESS:	16017 BASSETT ST		TELEPHONE:	(818) 442-5702
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 5	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Emma Arutiunian		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility staff did not provide resident's medical history to emergency personnel

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Subsequent Complaint visit at 1:09PM for the purpose of delivering the findings of a complaint investigation conducted by the Department’s Investigation’s Branch (IB) Investigator Laura Garcia. LPA initially met with facility staff Rosana. House Manager Emma Arutiunian, who is authorized to sign reports, arrived at 1:35PM. Administrator Hripsime Tavitian was unavailable at the time of the visit. Entrance interview conducted.

On 11/06/2020, LPAs Kelly Dulek and Brian Balisi conducted an initial complaint inspection, during which, between 9:10am - 10:45am LPAs conducted interviews with the staff and residents and conducted a physical plant tour. LPAs also obtained copies documentation relevant to the investigation. IB Investigator Garcia then conducted interviews with facility staff, residents, and other relevant parties on the following dates: 12/08/2020, 12/17/2020, 01/26/2021, and 02/02/2021. Document review took place on the following dates: 11/10/2020, 11/18/2020, 01/27/2021, and 10/01/2021. The following was then determined:
Report Continued on LIC-9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20201105122427

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT RESIDENTIAL CARE	FACILITY NUMBER: 197609923
	VISIT DATE: 02/23/2022

NARRATIVE

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During the initial complaint inspection on 11/06/2020, LPAs Balisi and Dulek attempted to gather information and documents for R1. Facility staff were unable to verbally provide much information to LPAs regarding R1’s medical or care needs. In addition, interview revealed that facility staff do not speak English as their first language and communication can be difficult without lead staff present to translate. During the LPA’s subsequent visit to the facility, when the House Manager was not present, the facility staff and LPA had trouble communicating verbally in English. Interview revealed that the lead caregiver had cared for R1 during their time at the facility and the remaining two (2) of two (2) staff had little knowledge or interaction with R1. Medical transport report from 10/03/2020 indicated no paperwork was provided to the ambulance provider, nor was medical history verbally communicated to the first responders. Additionally, paperwork received by LPA for the resident was dated 10/30/2019 although the resident was admitted to the facility on 09/30/2020 and had a change of condition which initiated R1’s admission to hospice care on 3/15/2020. Hospice records and hospice care notes were unable to be located at the facility during the initial complaint inspection. Medication administration and centrally stored medication records for the resident were found to be maintained by the hospice agency, rather than present at the facility. Based on record review and interview, the allegation that “facility staff did not provide resident’s medical history to emergency personnel” is deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20201105122427

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT RESIDENTIAL CARE	FACILITY NUMBER: 197609923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/09/2022 Section Cited HSC 87506(a)	1 2 3 4 5 6 7	87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	House manager agreed to complete a training for all staff on resident records maintenance with a qualified vendor and send LPA record of the training to include name of vendor, date held, participants, and topics covered by POC due date.
	8 9 10 11 12 13 14	Based on record review and interview, records for R1 were not updated when R1 was admitted to the facility although R1 had a change of condition, which poses a potential 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

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