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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609926
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:02:53 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
02/18/2021 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20210218113910
FACILITY NAME:SUNRISE AT LENNOXFACILITY NUMBER:
197609926
ADMINISTRATOR:GEVDZHYAN, ANI ASHLEYFACILITY TYPE:
740
ADDRESS:5339 LENNOX AVETELEPHONE:
(818) 616-4288
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:0CENSUS: 0DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Ani GevdzhyanTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Failure to provide adequate care/supervision resulting in injuries of unknown origin.
Failure to give medication according to physician's instructions.
Failure to accord residents with dignity in their personal relationships with staff, residents, and other persons.
Failure to serve food of the quality necessary to meet nutritional needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent telephonic complaint visit for the purpose to deliver findings for the above allegation. At 2:30 p.m., LPA Peraldi attempted to call the Licensee, however the Licensee did not answer.

During the initial visit, conducted virtually to implement mitigation measures related the Coronavirus Disease 2019 (COVID-19) on 02/25/2021 at 1:30 p.m., LPA Eva Miller interviewed the Administrator, Ani Gevdzhyan, conducted a virtual tour of the physical plant and requested pertinent files and documents. On 02/25/2021, LPA Miller conducted an interview with Staff #1 (S1). On 09/08/2021 LPA Peraldi interviewed the Administrator and requested additional information and documents. On 02/17/2023, LPA Peraldi attempted to conduct a telephonic interview with the Administrator. Additionally, on 02/17/2023 LPA Peraldi conducted a file review.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 29-AS-20210218113910
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: SUNRISE AT LENNOX
FACILITY NUMBER: 197609926
VISIT DATE: 03/27/2023
NARRATIVE
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In reference to the allegation: Failure to provide adequate care/supervision resulting in injuries of unknown origin. On 02/18/2021, the Department received a complaint in which it was alleged possible neglect or physical abuse of Resident #1 (R1). The complainant alleged that R1 had injuries of unknown origin including a small laceration on R1’s head and bruising on the upper arm. Interview with the Administrator conducted on 02/25/2021 stated that the Administrator did not observe any injuries on R1 prior to R1 leaving the facility. The Administrator stated that when R1 was first admitted in September 2020 that R1 did have a bump on R1’s head. The Administrator stated that R1 had surgery in December 2020 to remove the bump. The Administrator stated that R1’s physician report (dated 05/29/2020) did not mention the bump on R1’s head. The Administrator also stated that R1 developed another bump on top of the head prior to R1 leaving. The Administrator explained that R1 would pick at the bumps causing it to bleed. The Administrator denied any knowledge of bruising on R1. R1’s representative was aware of the bumps on R1’s head prior to R1’s admission to the facility. Additionally, on 02/18/2021 and 03/08/2021, LPA Miller requested additional information and photos of R1’s alleged injuries from the complainant, however the complainant did not provide the additional information or photos. During the file review conducted by LPA Peraldi on 02/17/2023, it was noted that the Administrator did not send all documents that were requested by LPA Miller on 02/25/2021. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

In reference to the allegation: Failure to give medication according to physician's instructions. On 02/18/2021, the Department received a complaint in which it was alleged that the facility staff did not follow R1’s physicians order when assisting with the self-administration of R1’s medication. Interview conducted on 02/25/2021, the Administrator stated that there have not been any medication errors involving R1’s medication. The Administrator stated that the only instance that R1 missed R1’s medication was when the refill did not arrive on time. The Administrator explained that R1’s representative was in charge of the refills. The Administrator did not provide additional information or documents regarding R1’s medication. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210218113910
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: SUNRISE AT LENNOX
FACILITY NUMBER: 197609926
VISIT DATE: 03/27/2023
NARRATIVE
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In reference to the allegation: Failure to accord residents with dignity in their personal relationships with staff, residents, and other persons. On 02/18/2021, the Department received a complaint in which it was alleged that the facility staff yelled at R1 and R1’s visitors on one occasion, (no specific date was provided). Interview with the Administrator conducted on 02/25/2021 stated that the Administrator did not observe facility staff raise their voices, yell or speak harshly to R1 or R1’s visitor. The Administrator stated that they have not received any complaints regarding staff being rude or unprofessional. Additionally, on 02/18/2021 and 03/08/2021, LPA Miller requested additional information regarding the above allegation from the complainant, however the complainant did not provide the additional information. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

In reference to the allegation: Failure to serve food of the quality necessary to meet nutritional needs. On 02/18/2021, the Department received a complaint in which it was alleged that the quality of food served to R1 was of unacceptable quality. Interview with the Administrator conducted on 02/25/2021 stated that the Administrator follows very specific instructions given to the facility for R1’s meals by R1’s representative. The Administrator explained that the facility ordered specific items such as bagels and lox from Costco as instructed. The Administrator stated that R1 was also served chicken, sandwiches, and rice. The Administrator explained that for lunch, once per week, the Administrator would have take-out delivered to the facility for the residents. Additionally, on 02/18/2021 and 03/08/2021, LPA Miller requested additional information and photos of R1’s meals, however the complainant did not provide the additional information or photos. Based on the available information obtained during the investigation, there is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

A copy of the report was issued to the former licensee via mail for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3