197610111-1-10-2024-31-AS-MVAO-D28VZH-20240207155247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 01/10/2024
Date Signed: 01/10/2024 09:29:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/04/2024 and conducted by Evaluator Leslie Ngo-Castaneda

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240104081845

FACILITY NAME:	CALIFORNIA STATE HEALTH GROUP LLC		FACILITY NUMBER:	197610111
ADMINISTRATOR:	ANDRANIK KAPIKYAN		FACILITY TYPE:	740
ADDRESS:	9526 SALOMA AVE		TELEPHONE:	(818) 660-7742
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Adranik Kapikyan- Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff is retaliating against resident for filing a complaint
Staff threatened resident with eviction

INVESTIGATION FINDINGS:

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There are two allegations:

On 1.10.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced visit to address this complaint.
LPA met initially met with staff Isiah Phiri who contacted the administrator. Administrator Andranik Kapikyan arrived at 10:20AM. LPA explained the reason for the visit.

Entrance interview conducted.

LPA conducted physical plant tour at 9:35am. At 9:40am LPA interviewed six (6) residents and reviewed resident records for any possible eviction notices.
Continue to LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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-20240104081845

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA STATE HEALTH GROUP LLC	FACILITY NUMBER: 197610111
	VISIT DATE: 01/10/2024

NARRATIVE

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Allegation: Facility staff is retaliating against resident for filing a complaint.

Interviews indicated that four (4) out of six(6) residents did not witness any retaliatory behavior from the Administrator towards resident #1 (R1).

No residents witnessed the Administrator approach or hear any conversations that may be taken as retaliatory. In interviewing the Administrator, he stated he did not approach the resident or saying anything regarding this allegation.

Therefore, after review of the information and due to a lack of witnesses the allegation cannot be corroborated and is unsubstantiated at this time. Allegation: Staff threatened resident with eviction.
Regarding the allegation of eviction, LPA conducted a file review during the investigation and did not observe any eviction notice in the file. LPA interviewed R1 and no eviction notice was received.

LPA interviewed the Administrator and the administrator indicated that no eviction notice was issued nor was there any threat to R1 to leave. Interview with the other (number ) resident were conducted and not one witnessed any threats made by the Administrator to R1.

Therefore, after review of the information and due to a lack of witnesses the allegation cannot be corroborated and is unsubstantiated at this time.

Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

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