197610111-3-20-2024-31-AS-NGID-D3PLNQ-20240325085439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 01/10/2024
Date Signed: 03/20/2024 03:17:52 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
01/04/2024 and conducted by Evaluator Leslie Ngo-Castaneda

COMPLAINT CONTROL NUMBER: 31-AS-20240104131120

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:	Nataly Canales- Staff		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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9

Facility has mold.

INVESTIGATION FINDINGS:

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This is an amendment of the original report issued 01-10-2024 to clarify the complaint findings.
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.
Today 1.10.2024 LPA conducted a tour of the home at 9:35AM. A black moldy patch was observed in bedroom three (3) on the base of the wall 2x2 inches in size. The Administrator (S1) was aware and acknowledged the presence of mold on the base of the wall in bedroom #3 and stated that there was a plumbing issue in bedroom #3 bathroom which caused the mold. The Administrator advice LPA that this is scheduled to be fixed and removed on 1.15.2024. An interview with staff member (S2) also confirmed and acknowledged mold formation in bedroom #3. Therefore, based on interviews, observation, and document review, there is sufficient information to support the allegation. Therefore, this allegation is deemed Substantiated. Deficiencies were issued and recorded on LIC 9099-D. Exit interview conducted. Report signed and delivered. Appeal rights delivered.

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-20240104131120

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 A 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 the licensee	1 2 3 4 5 6 7	The administrator will take all measures to maintain the facility free from mold. Administrator will submit updated documentation of repair to LPA via email for the invoice and picture of mold was removed on 1.21.2024.
	8 9 10 11 12 13 14	did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed mold in residents’ bedroom # 3. This poses a potential health, safety risk and personal rights violation to residents 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: 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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