197610102-4-24-2024-31-AS-NGID-D4PRVW-20240426132215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610102
Report Date: 04/24/2024
Date Signed: 04/24/2024 12:52:38 PM

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
04/16/2024 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20240416162206

FACILITY NAME:	ALLEVIATE CARE		FACILITY NUMBER:	197610102
ADMINISTRATOR:	EDGAR GHAZARYAN		FACILITY TYPE:	740
ADDRESS:	20930 GAULT STREET		TELEPHONE:	(818) 378-2772
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS: 6	DATE:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Edgar Ghazaryan, Administrator		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff does not maintain accurate records for resident.

INVESTIGATION FINDINGS:

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At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with the Administrator and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:05am, LPAs requested resident and staff roster. At 10:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Power of Attorney, etc., relevant to the investigation. At approximately 10:15am, 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 10:20am – 12:30pm, LPAs interviewed the Administrator, one (1) staff and four (4) out of six (6) residents.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240416162206

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: ALLEVIATE CARE	FACILITY NUMBER: 197610102
	VISIT DATE: 04/24/2024

NARRATIVE

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Allegation: Staff does not maintain accurate records for resident.

It was alleged that the suspected abuser (SA) presents himself/herself as R1's Power Of Attorney (POA) and has been signing consents on R1's behalf. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that R1 has a POA and all required documentation on file. Review of R1's file revealed that SA was assigned to be POA for R1 as of 11/15/2018. Based on interview and record review this allegation is deemed Unsubstantiated at this time.

No deficiency cited during today's visit.

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

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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