197610096-7-6-2023-31-AS-EMIR-CTPQBH-20230713120132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610096
Report Date: 02/10/2023
Date Signed: 07/06/2023 12:31:32 PM

Substantiated

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
10/14/2022 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20221014100314

FACILITY NAME:	HEALTHY LIFE SERVICE FACILITY		FACILITY NUMBER:	197610096
ADMINISTRATOR:	TADEVOSYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	15921 LIGGETT STREET		TELEPHONE:	(818) 810-5955
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Armine Dishoyan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility did not provide assistance to resident.
Facility did not provide incontinent care to resident.
Facility forced resident to sign up for hospice.

INVESTIGATION FINDINGS:

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On 02/10/2023 Licensing Program Analysts (LPAs) Evelin Rios and Mariana Agban arrived at the facility to conduct a subsequent unannounced complaint investigation. Upon arrival, LPAs were greeted by administrator Armine Dishoyan.

At 9:38 a.m., LPAs conducted a tour of the facility to ensure no immediate health and safety issues were present. No issues on todays visit were observed.
Allegation 1: Facility did not provide assistance to resident.
It is alleged staff did not assist resident #1 (R1) out of bed causing R1 to be bedbound while staying at the facility. On 10/18/2022 the LPA was able to tour the facility, interview the administrator regarding the allegation, and obtain and review pertinent information for the investigation. Administrator's interview revealed the facility confirmed staff did not assist R1 out of bed due to R1's weight and instead, staff relied on diapering R1. LPA’s review of R1’s physician report revealed R1’s nonambulatory status as based on their physical condition. Based on this information the allegation is deemed Substantiated. (9099 Continued)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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-20221014100314

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: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197610096
	VISIT DATE: 02/10/2023

NARRATIVE

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Allegation 2: Facility did not provide incontinent care to resident.
It is alleged R1 was only allowed 3 diapers per day. On 11/22/2022 LPA interviewed Licensee and Administrator regarding this allegation. Licensee stated that their policy is to check the residents’ diapers, in the morning, noon, night, and when needed not just 3 times a day. The administrator stated they do not change diapers and have been left alone in the facility to provide care for the residents, but no resident had needed a diaper change while she was at the facility alone. On 10/18/2022 LPA review of facilities Program states nonverbatim facility may retain a resident with manageable incontinence and the condition will be managed by the following, ensuring that the appropriately skilled professional develops the bowel and/or bladder program, if necessary, provides training to facility staff responsible for implementation of the program. R1’s records revealed an initial appraisal was not completed before R1’s admission to the facility and an incontinent care plan was not created for R1. The administrator stated there was no professionally developed incontinence care plan on file for R1. Based on the information obtained this allegation is deemed Substantiated.

Allegation 4: Facility forced resident to sign up for hospice.
Regarding the allegation the facility made the patient enroll in hospice. On 10/18/2022 an interview with the administrator regarding the allegation, revealed administrator and R1’s responsible party discussed acquiring "diapers" for R1. Administrator provided copies of text messages sent to R1's responsible party where the administrator states they called a hospice provider and later provided responsible party with two Hospice provider options. R1 was requesting an agency that provided physical therapy as per resident's Skilled Nursing Facility(SNF) Post Discharge Plan of Care. Review of SNF Discharge records revealed verbatim, patient will be referred to home-based palliative care. Interview with R1 revealed R1 did not believe themselves to be terminally ill and primary physician was not consulted when Hospice certification was made. Records of physician's certification for hospice benefits and physician's report revealed to have been completed by a physician other than R1's primary doctor four days after admission to the facility on 09/19/2023. R1 was admitted to facility on 09/15/2023. Based on the information obtained this allegation is deemed Substantiated.

Deficiencies issued per CA code of Regulations Title 22. Appeal rights issued. Report signed and delivered. Exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
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
10/14/2022 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20221014100314

FACILITY NAME:	HEALTHY LIFE SERVICE FACILITY		FACILITY NUMBER:	197610096
ADMINISTRATOR:	TADEVOSYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	15921 LIGGETT STREET		TELEPHONE:	(818) 810-5955
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Armine Dishoyan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
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5
6
7
8
9

Facility threatened resident.
Insufficient staff to meet resident’s needs.

INVESTIGATION FINDINGS:

1
2
3
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5
6
7
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On 02/10/2022 Licensing Program Analysts (LPAs) Evelin Rios and Mariana Agban arrived at the facility to conduct a subsequent unannounced complaint investigation.

Allegation #1: Facility threatened resident.

The Administrator states she was not aware of the resident being transferred out of the facility until the day it happened. Administrator called resident #1 (R1), responsible party (RP) and asked RP what was going on. The RP told the administrator, they couldn't discuss it and the transfer was already scheduled. Administrator told the RP they had a signed admission agreement. According to the Administrator, the RP told her if that is the case, RP will take them to court. The Administrator stated no threat was made to R1 or the RP and no action was taken against them for leaving abruptly. R1 was transferred out of the facility without incident.Based on the information obtained this allegation is deemed Unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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-20221014100314

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: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197610096
	VISIT DATE: 02/10/2023

NARRATIVE

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Allegation #2: Insufficient staff to meet resident’s needs.
Regarding the allegation it is alleged there was only one caregiver to assist 6 residents including R1. On 10/18/2022 the LPA was able to tour the facility and speak with three (3) out of the four (4) residents in care. LPA was also able to interview the administrator regarding the allegation. According to the Administrator, she has found it difficult to hire staff or retain staff. There are days when she has to be a caregiver or the Licensee has to stay all night as a caregiver. According to the Administrator there is usually two staff in the facility. Administrator has three full-time staff and one is on call. Residents stated that they receive immediate assistance when they call staff and they are happy with the care they receive at the facility. Based on the information obtained this allegation is deemed Unsubstantiated.

No deficiencies issued, this report was signed and delivered. Exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20221014100314

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: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197610096
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/24/2023 Section Cited CCR 87459(a)(4)	1 2 3 4 5 6 7	87459(a) The facility shall assess the person's need...Such activities shall include, but not be limited to: (4)Transferring, including the need for assistance in moving in and out of a bed or chair. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Resident is no longer in the facility. The regulation was addressed on todays visit. No POC required.
	8 9 10 11 12 13 14	Based on an interview with the Administrator, the administrator did not comply with the section cited above by not assisting R1 out of bed during the time the resident was in the facility. Which posed a potential Health and Safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 02/24/2023 Section Cited CCR 87625(b)(4)	1 2 3 4 5 6 7	(b) the licensee shall be responsible for the following:(4)Ensuring that bowel and/or bladder programs are designed by an appropriately skilled professional... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/ Administrator will identify residents in care that require a incontinent care plan and have a skilled professional develop a plan and administrator will keep plan in residents' file.
	8 9 10 11 12 13 14	Based on interview and record review, the administrator did not comply with the section cited above by not ensuring an incontinent care plan or a needs and services plan for R1 was created which posed a potential Health and Safety and personal rights risk to persons in care.	8 9 10 11 12 13 14

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20221014100314

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: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197610096
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/24/2023 Section Cited CCR 87633(a)(3)	1 2 3 4 5 6 7	(a)...to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (3)Hospice agency services are contracted for by each terminally ill resident or prospective resident individually, not by the licensee on behalf of a resident or prospective resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Resident is no longer in the facility. The regulation was addressed on todays visit. No POC required.
	8 9 10 11 12 13 14	Based on an interview with the Administrator and records review, administrator did not comply with the section cited above by offering assistance in finding a Hospice agency for R1 which posed a potential Health and Safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6