197610111-2-21-2024-31-AS-NGID-D332NT-20240304163315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:58:11 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
01/31/2023 and conducted by Evaluator Leslie Ngo-Castaneda

COMPLAINT CONTROL NUMBER: 31-AS-20230131130307

FACILITY NAME:	CALIFORNIA STATE HEALTH GROUP LLC		FACILITY NUMBER:	197610111
ADMINISTRATOR:	SIMITYAN, ARMENUI		FACILITY TYPE:	740
ADDRESS:	9526 SALOMA AVE		TELEPHONE:	(818) 660-7742
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Andranik Kapkyan- Administrator		TIME COMPLETED:	02:32 PM

ALLEGATION(S):

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Staff would not allow resident to come back to the facility.
Staff would not give resident their personal property.
Staff did not give resident medication

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Leslie Ngo-Castaneda conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Andranik Kapikyan and advised administrator of the allegations. During the course of the investigation, LPA conducted interviews clients in the facility at 1:010 PM. With the assistance of the staff at 1:05 PM LPA took a facility tour.

Allegation #1: Staff would not allow resident to come back to the facility

In regards to the allegation, it was reported that the resident did not allow resident to come back to the facility due to their monthly dues. Interviews with residents in the facility revealed that no incident occurred during their stay in the facility. They are all content with the facility and have no issues with coming and going out of the facility. Staff interviews reveal that they always try to meet the client’s needs. Review of facility records also confirms that staff training and facility program was reviewed by all the staff.
Cotinue 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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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-20230131130307

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: 02/21/2024

NARRATIVE

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Based on the information obtained, there was insufficient evidence to corroborate the allegation. Therefore, the allegation of staff not properly trained is unsubstantiated at this time.

Allegation #2: Staff would not give resident their personal property

Regarding the allegation, it was reported that staff would withhold resident belongings for dues not being paid. Interviews with residents do not corroborate with the allegation. Interviews with staff do not coincide with the allegation since the facility does not want any of the resident belongings. Therefore, based on the information obtained, the allegation of staff would not give residents their personal property is deemed unsubstantiated at this time.

Allegation #3: Staff did not give resident medication

In regards to the allegation, it was reported that the resident medication was withheld in the facility for not paying monthly dues. During the course of the visit, LPA did review of records of resident medication records and medication was given to the resident and signed-off by the staff on the Centrally Stored Medication and Destruction Records (CSMDR). Based on the information obtained, there was insufficient evidence to corroborate the allegation of resident medication being withheld. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued to the administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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