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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610054
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:04:27 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2022 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20221108101558
FACILITY NAME:LEO'S ASSISTED LIVING IIFACILITY NUMBER:
197610054
ADMINISTRATOR:ARAKELIAN, ARMINEFACILITY TYPE:
740
ADDRESS:7567 BOVEY AVENUETELEPHONE:
(310) 292-2992
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 2DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Khatchik DanielianTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Facility did not provide resident with a copy of their Admission Agreement
Staff took residents cell phone after calling 9-1-1
INVESTIGATION FINDINGS:
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At 9:30 a.m. on 01/12/2023 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. No immediate health or safety concerns were observed.
LPA Reed interviewed staff, family, and residents at 11:30 a.m. on 11/08/2022 and at 10:00 a.m. on 11/09/2022. LPA conducted record reviews at 12:45 p.m. on 11/08/2022 and at 9:35 a.m. on 11/09/2022. LPA toured the physical plant at 11:15 a.m. on 11/08/2022 and at 9:30 a.m. on 11/09/2022.

Regarding the allegation “Facility did not provide resident with a copy of their Admission Agreement”, it was alleged Resident #1 (R1) did not receive a copy of their admission agreement. From interviews, the Administrator stated R1 received a copy, which R1 denied. Other residents interviewed did have copies of their admissions agreements. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 6
Control Number 31-AS-20221108101558
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: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054
VISIT DATE: 01/12/2023
NARRATIVE
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Regarding the allegation “Staff took residents cell phone after calling 9-1-1”, it was alleged S1 took R1’s cell phone after calling 9-1-1. From interviews, S1 said they never took R1’s phone. R1’s roommate Resident #2 (R2) did not witness the event occur. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
11/08/2022 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20221108101558

FACILITY NAME:LEO'S ASSISTED LIVING IIFACILITY NUMBER:
197610054
ADMINISTRATOR:ARAKELIAN, ARMINEFACILITY TYPE:
740
ADDRESS:7567 BOVEY AVENUETELEPHONE:
(310) 292-2992
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 2DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Khatchik DanielianTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Staff unqualified in medication administration
Facility food is not nutritious
Medications accessible to residents
Resident bed in disrepair
INVESTIGATION FINDINGS:
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2
3
4
5
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7
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12
13
At 9:30 a.m. on 01/12/2023 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. No immediate health or safety concerns were observed.
LPA Reed interviewed staff, family, and residents at 11:30 a.m. on 11/08/2022 and at 10:00 a.m. on 11/09/2022. LPA conducted record reviews at 12:45 p.m. on 11/08/2022 and at 9:35 a.m. on 11/09/2022. LPA toured the physical plant at 11:15 a.m. on 11/08/2022 and at 9:30 a.m. on 11/09/2022.

Regarding the allegation “Staff unqualified in medication administration”, it was alleged Staff #1 (S1) did not assist with medications properly. From record review, the facility did not have training records for S1. From interviews, S1 confirmed they did not have training records at the facility. Residents noted multiple missed medication. From a physical plant tour, LPA observed accessible medications. Based on observations, interviews, and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 6
Control Number 31-AS-20221108101558
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: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054
VISIT DATE: 01/12/2023
NARRATIVE
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Regarding the allegation “Facility food is not nutritious”, it was alleged that meals served have not sufficient in quantity or quality. From interviews, residents noted the food served was not consistently nutritious and often lacking fruits or vegetables. Staff and residents noted Staff #2 (S2) was designated to shop for the facility. S2 had not been to work in over 3 days. From photo review, several meals served were lacking fruits and vegetables. R1 also showed LPA receipts from takeout ordered due to poor food quality. From observations, LPA saw a refrigerator full of fresh fruits and vegetables. Based on interviews, phot review, and observations, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D.

Regarding the allegation “Medications accessible to residents”, it was alleged S1 left medications unlocked. From physical plant tour on 11/08/2022, LPA observed medications unlocked and accessible. S1 immediately locked the medications afterwards. Based on observations, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. The deficiency was cited during a case management visit on 11/08/2022.

Regarding the allegation “Resident bed in disrepair”, it was alleged the brakes on R1’s bed were inoperable. From interviews, some residents noted their beds to be uncomfortable. From observations, the brakes on R1’s bed were not functional. Based on observations and interviews the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D.

Exit interview conducted. Copy of report provided. Appeal rights discussed.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20221108101558
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: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87411(c)
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87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training

This requirement was not met as evidenced by:
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Licensee has hired 2 additional staff with sufficient qualifications. Deficiency cleared during visit.
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Based on interviews and record review, the licensee did not comply with the section cited above in 2 out of 2 employees which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.
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Type B
02/10/2023
Section Cited
CCR
87555(b)(5)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural... backgrounds and food habits of residents.
This requirement was not met as evidenced by:
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Licensee will conduct a food requirement training for all staff and submit by POC due date.
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Based on interviews, the licensee did not comply with the section cited above in 3 out of 5 residents which posed a potential risk to the Health, Safety, or Personal Rights to persons 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20221108101558
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: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87307(a)(3)(A)
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87307 Personal Accommodations and Services (a)...The following provisions shall apply: (3) ...the licensee shall assure: (A) A bed... shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding.
This requirement is not met as evidenced by:
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Licensee will inspect all resident beds and ensure that resident are comfortable with their sleeping arrangements. Confirmation will be provided to LPA by POC due date.
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Based on interviews and observations, the licensee did not comply with the section cited above in 3 out of 5 residents which posed a potential risk to the Health, Safety, or Personal Rights to persons 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6