197610054-10-19-2023-31-AS-EMIR-D4NS4L-20240425133255

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610054
Report Date: 10/18/2023
Date Signed: 10/19/2023 09:22:22 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
10/09/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20231009085600

FACILITY NAME:	LEO'S ASSISTED LIVING II		FACILITY NUMBER:	197610054
ADMINISTRATOR:	DANIELIAN, KHATCHIK		FACILITY TYPE:	740
ADDRESS:	7567 BOVEY AVENUE		TELEPHONE:	(310) 292-2992
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Khachik Daniellan- Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff forced resident to assign licensee as resident's substitute payee.
Staff does not ensure bathroom needs are being met.
Staff does not allow resident to communicate with resident's family.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 10:00am, Licensing Program Analysts (LPAs) Mariana Agban, and Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs granted access to the facility by staff. Administrator arrived shortly after and LPAs explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:10am, LPAs requested resident and staff roster. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. LPAs conducted file review and observed missing Physcian's report, incomplete Admission Agreement for R1. At approximately 10:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:40am – 12:10pm, LPA interviewed the Administrator, two (2) staff and four (4) residents and the Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 2

Control Number 31-AS-20231009085600

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEO'S ASSISTED LIVING II	FACILITY NUMBER: 197610054
	VISIT DATE: 10/18/2023

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

Allegation: Staff forced resident to assign licensee as resident's substitute payee.
It was alleged that R1 was forced to assign the administrator as resident's substitute payee. Administrator denied the allegation. Administrator stated that R1 was responsible for their own finances. Administrator stated that for the 2 weeks R1 was in the facility R1 didn't provide any form of payment to the Administrator. Administrator contacted R1's family to become the POA of R1 to provide any sort of payment. Interview with 2 staff and 3 residents revealed that they didn't witness any resident being forced to assign licensee as resident's substitute payee.

Allegation: Staff does not ensure bathroom needs are being met.
It was alleged that R1's bathroom needs are not being met. Administrator denied the allegation. Interviews with 3 residents revealed that staff frequently assist residents with their bathroom needs. Residents stated that they have a call on button for immediate assistance as well as staff do rotation checks for each resident.

Allegation: Staff does not allow resident to communicate with resident's family.
It was alleged that R1 is being isolated and was prevented from contacting their family. Administrator denied the allegation. Administrator stated that R1 was homeless and didn't have family initially. Per Administrator, R1 didn't talk to their family for years and didn't know their contact information. Administrator stated R1 and R1's sister had many phone calls in regards the sister becoming the POA. Interview with 3 residents revealed that they are allowed to contact their families at any time.

Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, all allegations are Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2