197609923-6-16-2023-29-AS-DPEA-CU2UD2-20230724152848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609923
Report Date: 06/16/2023
Date Signed: 06/16/2023 12:27:21 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20221021163242

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: 6	DATE:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Emma Arutiunian - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint investigation visit to deliver the final findings for the allegation listed above. Upon arrival, LPA met with staff and explained the reason for the visit. Administrator Emma Arutiunian arrived shortly after.
On 10/24/2022, the initial complaint visit was conducted between approximately 9:30 a.m. - 2:30 p.m. During the visit, LPA conducted physical plant, interviewed staff as well as reviewed and obtained copies of pertinent documents relevant to the investigation. On 11/07/2022, LPA conducted a subsequent visit between approximately 11:30 a.m. - 12:30 p.m. and conducted physical plant, interviewed staff and responsible parties. LPA has attempted to contact reporting party on 10/24/2022 at 10:00am and 10:58am, 06/12/2023 at 11:40am and 06/12/2023, at 4:00pm, but was unsuccessful. LPA also subpoenaed and reviewed ABC Hospice records on 06/12/2023.
It was reported that facility staff expedited Resident #1 (R1) death by administering medication such as Morphine. It was further stated that an individual would arrive at the facility to administer the medication to R1, and that R1 was active prior to the start of the medication.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221021163242

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: 06/16/2023

NARRATIVE

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Continued from 9099
Information gathered during the course of the investigation reflected that R1 was admitted to the facility on 08/24/2021, after previously residing at a skilled nursing facility. Upon admission to the facility, R1 was also assessed and admitted into ABC Hospice. Based on the Comprehensive Nursing Assessment completed by hospice staff on 08/24/2021, R1 was noted to be bed bound, with a primary diagnosis of Alzheimer’s disease and secondary diagnosis of restlessness, agitation, chronic pain syndrome, dyspnea, and hypertension. Additionally, R1 was further noted to be awake, but lethargic, minimally responsive, and disoriented. R1 was pulse was also noted to be regular but weak with labored respirations. Per the hospice assessment reviewed, R1’s family was present during the visit and a Physician Orders for Life-Sustaining Treatment (POLST), which indicated Do Not Resuscitate (DNR) was signed by the family of R1. The assessment further reflected that, R1 was actively dying, due to R1 being lethargic, and non-responsive to verbal and touch stimuli. R1 was placed on comfort care and were prescribed Morphine Sulfate, as needed (PRN) along with Acetaminophen (PRN), Amlodipine Pesylate, Lorazepam (PRN), Olmesartan Medoxomil and Quetiapine Fumarate (PRN).

The hospice care visit notes for 08/25/2021, reflected that per facility caregivers, R1 was not drinking any fluids or taking any meals. Therefore, new orders were received from R1s hospice physician, and R1 was given Normal Saline (NS) via intravenous injection (IV). Per hospice records, R1 was given non-pharmacological methods to control pain on both 08/25/2021 and 08/26/2021. At approximately, 5:20 p.m. on 08/26/2021, hospice conducted an unscheduled visit after receiving a call from facility caregiver who reported that R1 was non-responsive to verbal, touch stimuli and had severe shortness of breath. Upon nurse assessment, R1 was cold to touch, had no pulse, respiration, and pupils were not reacting to light. R1 was pronounced deceased at 5:20 p.m. in comfort. Interviews conducted with R1’s family indicated that R1 was rapidly declining and actively dying upon admission to the facility and the family did not have any concerns of neglect or foul play by the facility.

Based on information gathered throughout the course of the investigation, the Department does not have sufficient evidence to determine that R1’s death was expedited by facility staff. Therefore, the above allegation “questionable death” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted/ No citations issued/ A copy of report provided to administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

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