197609953-3-4-2022-29-AS-JAPL-CCDW5E-20220310155901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609953
Report Date: 03/02/2022
Date Signed: 03/04/2022 08:03:28 AM

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
08/13/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20210813133851

FACILITY NAME:	GOLDEN AGE ASSISTED LIVING		FACILITY NUMBER:	197609953
ADMINISTRATOR:	SIRANUSH ALVADZHYAN		FACILITY TYPE:	740
ADDRESS:	11749 WELBY WAY		TELEPHONE:	(818) 433-4432
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 4	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	wi		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident's had questionable withdrawals from an account while in care.
Resident's personal belongings went missing while in care.

INVESTIGATION FINDINGS:

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On 03/02/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent complaint visit to deliver the findings regarding the above allegations. The LPA met with the Administrator Siranush Alvadzhyan at 1:20 p.m., and explained the reason for the visit.

On 08/18/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day day complaint investigation regarding the above allegations. LPA Urena arrived unannounced at the facility at 1:45 pm. LPA Urena spoke initially with caregiver Ruzanna Tonoyan. The caregiver contacted Administrator and the LPA waited for Administrator, Siranush Alvadzhyanto, to arrive and explained the reason for the visit. At 2:30 pm, LPA Urena conducted a physical plant tour and requested copies of staffs' schedule, Admission Agreement and resident documentation relevant to the investigation. The LPA reviewed staff and resident files, as well. The LPA interviewed residents and staff from 2:00 p.m. to 4:00 p.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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-20210813133851

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: GOLDEN AGE ASSISTED LIVING	FACILITY NUMBER: 197609953
	VISIT DATE: 03/02/2022

NARRATIVE

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Resident had questionable withdrawals from an account while in care. It is alleged that there were questionable withdrawals made by the facility from the Resident’s #1 (R1’s) account outside of what was paid for their short time stay at the facility. To investigate this concern, LPA Urena conducted interviews. The LPA interviewed S1, who stated that R1 was admitted to the facility on approximately 07/18/2021 and left the facility on 07/21/2021. S1 further stated that while R1 resided at the board and care facility, R1 only paid a fraction of the total monthly fee. LPA Urena asked S1 how much R1 paid for the four days R1 stayed at the facility? S1 stated that R1 paid $50.00 dollars a day, and R1 paid in cash. When LPA Urena asked S1 to provide copy of the receipt/s for the fees charged to R1, S1 stated that they did not have copies, because R1 did not request one; therefore, S1 did not make any receipts. When LPA Urena interviewed R1, LPA Urena asked them about the questionable charges made with the debit bank card, but R1 could not remember the charges. When the LPA asked R1 specifically about giving permission to anyone to use their bank card and providing them with the PIN number, R1 stated that they were not sure, and did not remember.

The LPA also conducted a record review on 08/24/2021 at 1:47 p.m. The LPA reviewed a bank statement submitted by the complainant; and although the bank statements provided by the complainant do show withdrawals made from the bank, the withdrawals do not identify the entity making the withdrawals, only the type of purchases made. The bank confirmed that $1300 was withdrawn from the bank account and that R1 did not make the withdrawals. The bank credited the resident’s bank account for the unauthorized charges and canceled the card. Additionally, none of the charges documented on the bank statement show charges made by the board and care facility. The Los Angeles Police Department is investigating the withdrawals. The facility record review revealed that an Admission Agreement (LIC 604A) for R1 was never created prior to the admission of R1 to the facility. Per S1, “R1 arrived in the middle of the night, and didn’t have time to create one, and then R1 left within a couple of days”. Consequently, there is no record on file which documents the fee charged for the month of board and care services.

Based on the investigation, although the resident did have unauthorized withdrawals from their bank account while in care, there is insufficient evidence to support that a facility staff made the unauthorized withdrawal at this time. The allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210813133851

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: GOLDEN AGE ASSISTED LIVING	FACILITY NUMBER: 197609953
	VISIT DATE: 03/02/2022

NARRATIVE

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Resident’s personal belongings went missing while in care. It is alleged that the R1’s personal belongings went missing while R1 was in care and staying at the board and care facility. It is alleged that the missing personal belongings are medication, clothing, bank ATM card, and a Cal Fresh card. To investigate this concern, LPA Urena interviewed S1, R1, and RP. The LPA also conducted record review. The LPA interviewed S1 about the personal belongings and S1 stated that the resident was admitted to the facility approximately on 07/18/2021. S1 stated “R1 didn’t really didn't have many have belongings, only a sitting walker and a couple of bags of clothing. R1 didn’t have any meds”. The S1 stated that “when R1 left, R1 called transportation, got her stuff and left”. The record review revealed that Client/Resident Personal Property and Valuables (LIC 621) form was not completed by the facility staff at the time when R1 was admitted to the board and care facility. LPA Urena interviewed R1 and asked them about the missing personal belongings. R1 stated, "Nobody stole my belongings, only shoes." When LPA Urena asked R1 who stole their shoes, R1 could not say.

Based on the investigation, there is insufficient evidence to support the allegation that the Resident’s personal belongings went missing while in care. The allegation is deemed Unsubstantiated at this time.

No deficiencies were cited at this time. Exit interview conducted with administrator Siranush Alvadzhyan . Signatures were obtained. A copy of report was issued via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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