197610111-1-18-2024-31-AS-NGID-D36Q87-20240308105616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 01/10/2024
Date Signed: 01/18/2024 12:38:27 PM

Substantiated

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
12/27/2023 and conducted by Evaluator Leslie Ngo-Castaneda

COMPLAINT CONTROL NUMBER: 31-AS-20231227160159

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:	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Adranik Kapikyan- Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not ensure a safe and healthful environment is provided for resident.
Staff do not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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This an AMNDED report as further rewview of defciencies and fine that was issued incorrectly. This is to state that NO FINE has been cited and issued to facility.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent complaint visit to deliver the finding for the above stated allegation.
LPA met with the administrator and explained the reason for the visit.
Entrance interview.

Allegation: Staff do not ensure a safe and healthful environment is provided for resident.

On 01-03-2024 LPM Gillyard and LPA Ngo-Castaneda initiated the visit. On this day, the home was observed to have a malodorous scent of urine. A black moldy patch was observed in room (3) on the base of the wall in size of 2x2. The wall paint was puckers due to water damage. The Administrator made observations and acknowledged indicating that there needs to be plumbing work done in the hallway bathroom.
Continue to LIC 9099-C

Substantiated

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-20231227160159

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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Today LPA conducted a tour of the home (time). LPA observed malodorous urine odor upon entering the home. During the facility tour LPA observed mold which was seen in resident bedroom #3 on the left side bottom corner wall by the entrance as seen on 01-03-2023. At 9:35am LPA interview with R1 revealed and confirmed that there is mold in the facility of bedroom #3. In addition, interviews indicate that R2 would throw soiled diaper across bedroom #2 wall. Upon further inspection of the facility LPA observed that bedroom #4 has an odor.

Interview with all staff members, confirmed that the facility has did not provide a clean and safe environment for the residents in care. The facility tried to paint over the mold, repair and clean the rooms but was unsuccessful.

Allegation: Staff do not safeguard resident's personal belongings.

Upon further investigation it was also alleged that facility did not safeguard resident # 1 personal belongings. Upon resident interview and review of pictures and videos it was discovered that R2 would wear roommates clothing without permission. R1 did not give permission to roommate for them to go through their belongings.

Staff did not redirect roommate.

Therefore, based on interviews, observation, and document review, there is a sufficient information to support the allegation. Therefore, this allegation is deemed Substantiated.

Deficiencies were issued and recorded on LIC9099D.

Exit interview conducted. Report signed and delivered. Appeal rights delivered.

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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Control Number 31-AS-20231227160159

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/10/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by: Based on inspection, and observation.	1 2 3 4 5 6 7	The administrator will take all measures to maintain the facility free from odor and mold. Administrator will submit updated documentation of repair to LPA via email 1.22.2024. This is an AMEND that no civil penalty is issued in the facility.
	8 9 10 11 12 13 14	The licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others.LPA observed mold and odor in residents’ bedrooms and facility entrance. This poses a potential health, safety risk and personal rights violation to residents in care.	8 9 10 11 12 13 14
Type B 01/10/2024 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	Personal Accommodations and Services (d) The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator will need to provied a lock to keep the belongings safe for the residents by 1.20.2024
	8 9 10 11 12 13 14	This was observed with LPM and LPA R1 used a white shoelace like rope to tie the handles of the cabinet to safeguard belongings. The allegation is substantiated and is an immediate health and safety risk to residents 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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

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