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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610031
Report Date: 07/13/2023
Date Signed: 07/14/2023 08:16:29 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
01/03/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230103142731
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:
07/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nirvana GhaemiTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not safeguard residents’ personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sandra Urena and Emili Peraldi conducted a subsequent visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit.

On 01/11/2023, Licensing Program Analysts (LPA’s) Sandra Urena, and Ashley Smith conducted an initial 10-day unannounced visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit. At 9:25 a.m., the LPAs conducted a brief tour of the physical plant. From 9:30 a.m. to 10:21 a.m. LPAs conducted resident interviews, and from 10:30 a.m. to 11:08 a.m. LPAs conducted staff interviews. Record review was done from 11:10 a.m. to 11:25 a.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: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
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 7
Control Number 29-AS-20230103142731
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: 07/13/2023
NARRATIVE
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Staff did not safeguard residents’ personal belongings.

On the allegation that ‘Staff did not safeguard resident personal belongings’; it is the complainant’s concern that the responsible parties for R1 purchased new clothes and they were missing. To investigate the allegation, the LPAs conducted interviews. The Administrator stated that they believe that R1’s items were stolen by a former staff. The administrator called R1’s family and said they could provide new clothes or pay for what was taken. Additionally, the administrator stated that they did not have an inventory of R1’s items because many of the residents didn’t have ‘much’.

However, the administrator said they were going to start to log the new items and said they were going to do this with R1’s family. The interview with R1’s responsible parties revealed that they had communicated with the administrator about the missing clothing items, and that the administrator gave them two different reasons for the clothing missing. First the administrator stated, ‘R1 must have thrown their clothes away’, and when the responsible parties replied, ‘But staff are supposed keep an eye on residents’, then the administrator changed the reason to, ‘Probably the staff no longer working at the facility must have taken them’. The administrator asked about the total value of the clothing missing, and the responsible party stated that it was somewhere in the amount of $200 dollars. The responsible parties for R1 stated that they had received payment for the lost clothes.



Based on the information obtained through interviews, there is sufficient evidence to support the allegation that staff did not safeguard residents’ personal belongings. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, and the Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D):

Citations were issued. Exit interview conducted, today's report, and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20230103142731
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2023
Section Cited
CCR
87217(b)
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8721(b)Safeguard for Personal Property & ValuablesEvery facility shall take appropriate measures to safeguard residents' ... personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles...This requirement is not met as evidenced by:
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POA: Administrator reimbursed the RP for the missing clothing. The POA has been cleared.
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Based on interviews, the licensee did not comply with the section cited above when the licensee failed to safeguard and provide receipts for all personal property…, which resulted in R1’s clothing being lost, which posed a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
01/03/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230103142731

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:
07/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nirvana GhaemiTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not prevent resident sustaining injury due to fall.
Staff left resident in soiled diaper for extended period of time.
Staff are not providing resident with adequate food service.
Staff did not ensure resident was given showers.
Staff did not provide privacy for resident.

INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sandra Urena and Emily Peraldi conducted a subsequent visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit.

On 01/11/2023, Licensing Program Analysts (LPA’s) Sandra Urena, and Ashley Smith conducted an initial 10-day unannounced visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit. At 9:25 a.m., the LPAs conducted a brief tour of the physical plant. From 9:30 a.m. to 10:21 a.m. LPAs conducted resident interviews, and from 10:30 a.m. to 11:08 a.m., LPAs conducted staff interviews. Record review was done from 11:10 a.m. to 11:25 a.m.

Continues on LIC9099AC...
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: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
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 7
Control Number 29-AS-20230103142731
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: 07/13/2023
NARRATIVE
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Pg.2 Staff did not prevent resident sustaining injury due to fall.

On the allegation of ‘Staff did not prevent resident sustaining injury due to fall’, it is the complainant’s concern that R1 can’t walk or move that well. To investigate the allegation the LPA conducted interviews. The interview with the complainant on 01/06/2023 at 9:54 a.m., revealed that R1 can hardly walk and stand by themselves. R1 needs to be in a wheelchair and be assisted when they need to go to the bathroom or take a shower. Although the medical record review indicated that R1 is ambulatory, record review of a needs assessment plan dated between 03/21/2021 to 12/29/2022 indicates that R1 is at risk of falls; the assessment plan indicated that R1 should be monitored and encouraged to use a walker or wheelchair. Record review revealed that R1 has a condition that affects their mobility. Interview with the administrator revealed that R1 goes to the bathroom on their own, and that R1 is also at risk for falls, however the administrator did not elaborate as to the measures taken by staff to ensure that R1 is monitored and or assisted while going to the bathroom on their own to prevent falls. The LPA interviewed the staff who stated that some residents are at risk of falls, however staff stated that they monitor the residents while they are awake, and sometimes the residents get up in the early hours of the morning or night and they may sustain falls while trying to get up from the bed or go to the bathroom on their own. To investigate the allegation the LPA interviewed residents, staff, and administrator. Two out of three residents were able to answer questions related to the falls. Two stated that they had not sustained falls.

Based on the information obtained through interviews, and record review, although there is sufficient evidence to support the allegation that two residents out of five residents sustained falls while in care, the falls occurred while the resident attempted to independently go to the bathroom either at night or early morning. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff left resident in soiled diaper for extended period of time.



On the allegation that ‘Staff left resident in soiled diaper for extended period of time’; it is the complainant’s concern that residents smelled like they were wearing soiled diapers. To investigate the allegation, the LPAs conducted interviews. The administrator claimed that R1 goes to the bathroom on their own, but that R1 also wears a diaper, however, R1 doesn’t use it, and primarily goes to the restroom and uses the toilet. The administrator further stated that the residents all have access to the diapers, but staff will also provide the resident with a new diaper as needed.
Continues on page 3.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20230103142731
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: 07/13/2023
NARRATIVE
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Pg. 3
The interview with the complainant revealed that they don’t know how often the staff changes the residents’ diapers and could not say how many other times the residents smelled like they were wearing soiled diapers. Staff interviews revealed that R1 did not need assistance but said that they needed to monitor them, so staff will check in with R1 to make sure they are using the restroom. Record review did not indicate that R1 has incontinence needs.

Based on the information obtained through interviews, although the allegation may have happened or is valid, there is not sufficient evidence to prove that the staff left the resident in soiled diapers for an extended period of time. Therefore, the allegation is Unsubstantiated at this time.

Staff are not providing resident with adequate food service.


On the allegation that ‘Staff are not providing resident with adequate food service’; it is the complainant’s concern that responsible parties for R1 purchase snacks for R1, however, when R1 runs out of snacks, the staff give R1 snacks that are for diabetics, and R1 is not diabetic. To investigate the allegation, the LPAs interviewed the administrator, staff, residents, and responsible parties. The staff stated that none of the residents are on special diets, but a couple of residents are diabetic, and staff cook meals that are low in salt. The administrator stated That R1’s responsible parties do bring R1 protein shakes, however the physician’s report does not state that R1 requires a special diet. R1’s responsible parties stated that they provide the facility with protein shakes for R1, because R1 needs to gain weight. However, R1’s responsible parties stated that R1 was being given by staff drinks designed for diabetics. Record review does not indicate that R1 is on a special diet.

Based on the information obtained through interviews, and record review, there is not sufficient evidence to prove that the staff are not providing resident with adequate food service. Therefore, the allegation is Unsubstantiated at this time.

Staff did not ensure resident was given showers.


On the allegation that ‘Staff did not ensure resident was given showers’, it is the complainant’s concern that when R1’s visited the facility, they noticed that R1 was dirty, and had not had a bath. To investigate the allegation, the LPAs conducted interviews.

Continues on Pg.4

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

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20230103142731
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: 07/13/2023
NARRATIVE
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Pg. 4
The interview with the staff revealed that R1 needs assistance to shower, and that staff provide assistance to R1 twice a week. The administrator’s interview revealed that any staff can assist R1 with showers. The interview with R1’s responsible parties revealed that on a recent visit R1 had different bad smells, and definitely could tell that R1 had not been given a shower recently. When asked by the LPA if they had asked staff how often they assisted R1 with showers, the responsible parties stated, ‘No’.

Based on the information obtained through interviews, although the allegation may have happened or is valid, there is not sufficient evidence to prove that staff did not ensure resident was given showers. Therefore, the allegation is Unsubstantiated at this time.

Staff did not provide privacy for residents.


On the allegation that ‘Staff did not provide privacy for resident’, it is the complainant’s concern that while the responsible parties for R1 were trying to communicate with R1 via phone, the staff took the phone away from R1. To investigate the allegation, the LPAs interviewed the administrator and the responsible parties for R1. The administrator said that if residents want to use the phone, they can and there are no restrictions; the staff can also call if a resident requests assistance, but said they also leave the resident alone when they are on the phone. Administrator denied claims that they had ever received complaints about phone calls being interrupted. The interview with R1’s responsible parties revealed that on two different occasions when they were speaking with R1 on the phone, R1 was trying to explain, and tell me something, when a staff (don’t know who) abruptly took the phone away from R1, consequently R1 could not finish telling the responsible parties what they wanted to say.

Based on the information obtained through interviews, although the allegation may have happened or is valid, there is not sufficient evidence to prove that staff did not provide privacy for resident. Therefore, the allegation is Unsubstantiated at this time.

Exit interview conducted. Today’s report was reviewed and issued.

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

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7