197609927-9-1-2021-31-AS-NGID-CLXMYU-20221209090202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609927
Report Date: 09/01/2021
Date Signed: 09/01/2021 07:12:34 PM

Substantiated

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: 6	DATE:	09/01/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Anzhelika Alikhanyan, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff could not understand resident's need due to their language barrier

INVESTIGATION FINDINGS:

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At approximately 9:20am Licensing Program Analyst (LPA) Angela Panushkina, conducted an unannounced complaint visit to the above facility. Upon arrival LPA was greeted by staff on duty. The Administrator arrived shotrly after and the LPA informed her of the reason for the visit.

Allegation: Facility staff could not understand resident's need due to their language barrier.
At appoximately, 10:15am LPA conducted an interview with the Administrator and it was confirmed that previously Administrator hired a caregiver and due to lack of communication issues, the caregiver was terminated and replaced by another caregiver. This complaint allegation is substantiated.

Exit Interview conducted, appeal rights explained and copy of this report was given to the Administrator.
.

Substantiated

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: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/01/2021 Section Cited CCR 87411(d)(3)	1 2 3 4 5 6 7	Personnel Requirements:All personnel shall be given on the job training or have related experience in the job assigned to them... (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.The requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator already terminated and replaced staff with another staff that can understand residents and meet their daily needs. This deficiency is cleared.
	8 9 10 11 12 13 14	Based on an interview with the Administrator it was confirmed that the Administrator hired a caregiver that couln't properly communicate with the residents. This poses a potential health and safety risk to clients 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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC9099 (FAS) - (06/04)

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