<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610031
Report Date: 12/14/2022
Date Signed: 12/15/2022 10:29:01 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/07/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20221207153019
FACILITY NAME:CARMEL OAKS ASSISTED LIVINGFACILITY NUMBER:
197610031
ADMINISTRATOR:NIRVANA GHAEMIFACILITY TYPE:
740
ADDRESS:4607 LENNOX AVETELEPHONE:
(818) 277-1948
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 6DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Nirvana GhaemiTIME COMPLETED:
04:06 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility operating out of ratio.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2022, Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced visit to investigate the allegation listed above. The LPA arrived at the facility at 11:45 a.m., and was greeted by the staff. The staff contacted the Administrator Nirvana Ghaemi via telephone and made them aware of the visit. The LPA waited for the Administrator to arrive, and explained the reason for the visit.

At 12:12 p.m., the LPA, and the staff conducted a brief physical plant tour of the facility. At 12:45 p.m. The LPA requested residents, and staff records, and medication logs. The LPA reviewed the records from 12:50 p.m. to 1:55 p.m.



Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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 29-AS-20221207153019
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: CARMEL OAKS ASSISTED LIVING
FACILITY NUMBER: 197610031
VISIT DATE: 12/14/2022
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
On the allegation that the ‘Facility is operating out of ratio’, the Reporting Party’s (RP) concern is that the facility is serving more residents than it is licensed to serve. The facility is licensed to serve six (6) residents. The facility’s record review revealed that eight (8) residents were admitted, and living at the facility from 10/18/2022 to 12/06/2022. One resident left on 12/06/2022, and another resident left the facility on 12/09/2022. The LPA interviewed residents' responsible parties, and the interviews revealed that the eight (8) residents were living at the facility between the months of October 2022 and December 2022. The LPA interviewed the administrator, and the interview revealed that eight (8) residents were admitted to the facility, and were residing during a specific time of period between 10/2022 and 12/2022.

On 12/06/2022, during a Case Management Deficiencies visit, the facility was cited Pursuant to Title 22 of the CA Code of Regulations: 87204-(a) A licensee shall not operate a facility beyond the condition and limitations specified on the license, including specifications of the maximum number of persons served who may receive services at any one time.

Therefore, based on the records review, and interviews, the allegation that the ‘Facility is operating out of ratio’ is deemed to be Substantiated at this time. No additional citations were issued at this time.

Exit interview was conducted with the Administrator. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
12/07/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20221207153019

FACILITY NAME:CARMEL OAKS ASSISTED LIVINGFACILITY NUMBER:
197610031
ADMINISTRATOR:NIRVANA GHAEMIFACILITY TYPE:
740
ADDRESS:4607 LENNOX AVETELEPHONE:
(818) 277-1948
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 6DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Nirvana GhaemiTIME COMPLETED:
04:06 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff administers resident’s medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2022, Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced visit to investigate the allegation listed above. The LPA arrived at the facility at 11:45 a.m., and was greeted by the staff. The LPA waited for the Administrator to arrive, and explained the reason for the visit. At 12:12 p.m., the LPA, and the staff conducted a brief physical plant tour of the facility. No deficiencies were found at this time. At 12:45 p.m. the LPA requested residents, and staff records, and medication logs. The LPA reviewed the records from 12:50 p.m. to 1:55 p.m.
On the allegation that the “Facility staff administers medication’, the RP’s concern is that facility’s staff are not trained to assist residents with prescribed medications. To investigate the allegation, LPA Urena reviewed the staffs’ qualifications, and training to assist residents with medication. Record review revealed that the staff received the annual required training on how to assist residents with medication on 05/06/2022. Therefore, the allegation that the facility staff are not trained to assist with medication, is deemed Unsubstantiated at this time. No citations were issued at this time. Exit interview was conducted with the Administrator. A copy of the report was issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3