197609945-4-17-2024-31-AS-TAGD-D4SVHQ-20240429162730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609945
Report Date: 04/17/2024
Date Signed: 04/17/2024 01:59:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
04/12/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240412122923

FACILITY NAME:	SUN VALLEY RESIDENTIAL MANOR LLC		FACILITY NUMBER:	197609945
ADMINISTRATOR:	HAKOBYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	8667 HERRICK AVENUE		TELEPHONE:	(818) 823-0955
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 5	DATE:	04/17/2024
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Rebeka Durgaryan - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff is violating the resident's personal rights by not allowing him to go outside of the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan and Leizl Dela Cerra conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with administrator Rebeka Durgaryan and explained the reason for the visit.

LPAs conducted physical plant tour at 9:42 AM, requested copies of facility documents relevant to the investigation at 10:02 AM and interviewed staff and residents from 10:30 AM to 12:30 PM. It was alleged that Resident #1 (R1) was not allowed to move out of the facility for non-payment. LPAs' record review today at 12:30 PM revealed that R1 is currently on Hospice Care services and bed bound and needed a lot of care due to R1's medical condition. LPAs' observation during physical plant tour and during interview with R1 confirmed that R1 is non ambulatory, and bed bound.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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-20240412122923

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUN VALLEY RESIDENTIAL MANOR LLC	FACILITY NUMBER: 197609945
	VISIT DATE: 04/17/2024

NARRATIVE

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(continued from LIC 9099)

LPAs' interview with R1 at 10:40 AM also confirmed that R1 was not able to get up on R1's own due to R1's fall way back in December of 2023 which caused R1 to be hospitalized and subsequently went to a Skilled Nursing Facility (SNF) and ended up at this facility on 01/19/24. Further interview with R1 also revealed that R1 wanted to go home to R1's own house but R1 also admitted that R1 hadn't paid the facility and owes the facility money. LPAs' interview with staff at 11:20 AM also confirmed that R1 was not able to get up on R1's own that is why there is a Hoyer lift on R1's bedside. LPAs' interview with the administrator at 11:55 AM revealed that R1 was already under hospice care when R1 moved in the facility. R1 told her that R1 wanted to move out back to R1's home but she told R1 that R1 needed a clearance from R1's doctors and needed to be assessed by a social worker if R1 could be given assistance or able to live on R1's own. The administrator added that a Hospice social worker assessed R1 and told R1 that R1 could not leave the facility at this time due to R1's medical condition and ensure that R1 will have a much-needed care provider if when R1 moved out. Administrator denied stopping R1 from leaving the facility at any time.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC9099 (FAS) - (06/04)

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