197609927-11-29-2022-31-AS-NGID-CLXMYT-20221209090202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609927
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:23:29 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2021 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20210825085720

FACILITY NAME:	ASSISTED SENIOR CARE FACILITY		FACILITY NUMBER:	197609927
ADMINISTRATOR:	ANZHELIKA, ALIKHANYAN		FACILITY TYPE:	740
ADDRESS:	7039 CLAIRE AVE		TELEPHONE:	(818) 988-9724
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 3	DATE:	11/29/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rima Agaronyan, Designee		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Resident sustained pressure wound while in care
Facility staff did not notify representative of resident's change of condition
Facility staff did not seek timely medical attention

INVESTIGATION FINDINGS:

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At 1:30pm Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with the Designee and explained the reason for the visit.

LPA conducted a physical walk through, at approximately 1:40pm to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during this visit.

On 08/27/21, LPA Shanahan conducted an initial 10-day complaint visit to the facility and gathered pertinent documentation relevent to this investigation. On 09/01/21 a subsequent visit was conducted by LPA Ruiz and five (5) out of eight (8) allegations were completed and the report was delivered. For the remaining three (3) allegations, LPA Panushkina requested R1's Medical Records from Kaiser Permanente on 10/18/22 and received the results on 10/27/22. Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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 3

Control Number 31-AS-20210825085720

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: ASSISTED SENIOR CARE FACILITY	FACILITY NUMBER: 197609927
	VISIT DATE: 11/29/2022

NARRATIVE

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Lastly, an interview with the Administrator was conducted on 10/25/2022, by LPA Panushkina, regarding these allegations.

Allegation: Resident sustained pressure wound while in care

Interview with the Administrator revealed that R1 was admitted to this facility on 04/03/21 and did not sustained any pressure wound while in care from the date of admission through September 2021. In addition, review of Medical Records received on 10/27/22 from Kaiser Permanente, revealed that from 06/13/21 to 09/01/21, R1 was admitted and was being treated at the hospital due to other medical issues not related to pressure injury. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time.

Allegation: Facility staff did not notify representative of resident's change of condition

Interviews with the Administrator revealed that R1 attempted to contact the doctor's office to schedule a same day appointment, but nothing was available. Interview also revealed that upon admission R1's responsible party agreed to provide a transportation to R1's medical/dental appointments. Administrator informed LPA that R1's responsible party was very well aware of R1's condition and a scheduled appointment with the primary doctor around August 2021. In addition, review of Medical Records received on 10/27/22 from Kaiser Permanente, revealed that "on 08/09/2021: R1 called to request an in office appt with PCP during the weeks of 8/9/21 or 8/16/21 due to Edema. No appts avail. Please call back." Medical Records also revealed that R1's doctor's appointment was scheduled for 08/13/21. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time.

Allegation: Facility staff did not seek timely medical attention

Interview with the Administrator revealed that R1 always refused to be taken to an Emergency Room (ER) and preferred to be seen by a primary doctor first. Administrator informed LPA that after R1's doctors appointment got booked, R1 immediately notified the responsible party (RP), since RP was in charge to provide medical/dental transportation to R1. Although, R1's doctors' appointment had already been scheduled, interview with the Administrator revealed that the facility did provide timely medical attention by calling 911.

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20210825085720

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: ASSISTED SENIOR CARE FACILITY	FACILITY NUMBER: 197609927
	VISIT DATE: 11/29/2022

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	Review of Medical Records also revealed that R1 was admitted to the Emergency Room (ER) three (3) days prior to R1's primary doctors appointment. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3