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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:25:29 PM

Substantiated


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
04/07/2023 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20230407084204
FACILITY NAME:CALIFORNIA STATE HEALTH GROUP LLCFACILITY NUMBER:
197610111
ADMINISTRATOR:ANDRANIK KAPIKYANFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 660-7742
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Andranik KapikyanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff refuse to provide resident with wound care.
Staff refuse to administer resident's medications as prescribed.
Staff do not ensure residents have access to food/snacks between meals.
Licensee is not following resident eviction procedures.
INVESTIGATION FINDINGS:
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On 4/14/2023, Licensing Program Analysts (LPAs) Melissa Ruiz and Angela Panushkina, arrived at the facility to conduct an initial complaint investigation. Upon arrival, LPAs were greeted by S1, and LPAs later met with the Administrator Andranik “Nick”. An entrance interview was conducted, and the purpose of the visit was explained.

Allegation: Staff refused to provide resident with wound care.

To investigate this allegation, LPAs conducted record review for R1 at 10:40 a.m. and LPAs did not observe a hospice care plan outlining the care R1 was receiving. LPAs also did not observe any hospice notes for R1’s hospice nurse visits. In addition, LPA requested the Administrator obtain hospice notes and records, and Administrator only provided a medication list from the hospice agency, no other documents were provided at the time of this report. Based on record review, the allegation is deemed Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20230407084204
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: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111
VISIT DATE: 04/14/2023
NARRATIVE
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Allegation: Staff refuse to administer resident's medications as prescribed.

To investigate this allegation, LPAs conducted a medication review at 10:15 a.m. LPAs reviewed medication for R1 and LPAs requested Centrally Stored Medication and Destruction Record for R1 and R1’s physician report. Administrator did not provide the Centrally Stored Medication and Destruction Record, and the physician report for R1 was incomplete, missing R1’s diagnosis and medication list. Due to LPAs observation and record review, the allegation above is Substantiated at this time.

Allegation: Staff do not ensure residents have access to food/snacks between meals.

To investigate this allegation, LPA conducted an interview with six out of six residents from 10:30 a.m. to 11:30 a.m. Two (2) out of six (6) residents stated that they do not have access to the kitchen after dinner time, and there was an instance where R2 went to the groceries and bought food and snacks, however the Administrator told R2 they could not do that. LPAs interviewed the Administrator at 12:00 p.m., and the Administrator stated that they did in fact tell R2 that buying food for themselves was not fair to the other residents, and that there was already food at the facility. Based on an interview with two out of six residents and an interview with the Administrator, the allegation mentioned above is deemed substantiated at this time.

Licensee is not following resident eviction procedures.

To investigate this allegation, LPA conducted an interview with one (1) out of six (6) residents at 10:30 a.m. and R1 stated that the Administrator verbally told them that they will evict them for failure of non-payment. R1 stated the Administrator told them they sent an eviction notice to “Licensing”. An interview with the Administrator at 12:00 p.m. revealed that they verbally told R1 they are evicting them, and the Administrator stated that he sent LPA Ruiz an eviction notices via e-mail. LPA conducted a record review and LPA confirmed there was no e-mail sent by the Administrator. Based on interviews with the Administrator and R1 and record review, the allegation mentioned above is deemed substantiated at this time.

Deficiencies issued per CA Code of Regulations, Title 22. Appeal rights issued. Report signed and delivered. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20230407084204
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: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
87458.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities
(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement is not met as evidenced by:
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Licensee agrees to conduct training for themself and staff regarding residents' personal rights, specifically regarding food and submit a copy of proof of training to CCL on or before the POC date.
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Based on interviews conducted, licensee failed to ensure that residents have access to the food/snacks at any time. This poses a potential health and safety or personal rights risk to the resident in care.
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Type B
04/21/2023
Section Cited
CCR
87224(f)
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87224(f) Eviction Procedures.
A written report of any eviction shall be sent to the licensing agency within five (5) days.

This requirement is not met as evidenced by:
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Licensee agreed to provide a written statement to CCL by the indicated date confirming their understanding and intent to abide by the cited regulation. Furthermore, all supervisory staff members shall be re-trained on proper eviction procedures.
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Based on interviews and record review the licensee did not comply with the section cited above by not notifying the licensing of R1's eviction. This poses a potential Health and Safety and Personal Right risk to residents in care.
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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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20230407084204
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: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2023
Section Cited
CCR
87465(h)(6)(A)-(F)
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87465(h)(6)(A)-(F)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... (A)...(F)...

This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff by 04/16/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 04/26/2023
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Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed medications on CSMDR, which poses an immediate health and safety risk to residents in care.
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Type A
04/16/2023
Section Cited
HSC
1569.73(a)(5)
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1569.73(a) (5) An agreement has been executed between the facility and the hospice regarding the care plan for the terminally ill resident or terminally ill person to be accepted as a resident. The care plan shall designate the primary caregiver, identify other caregivers, and outline the tasks the facility is responsible for performing and the approximate frequency with which they shall be performed. The care plan shall specifically limit the facility’s role for care and supervision to those tasks allowed under this chapter."

This requirement is not met as evidenced by:
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Administrator agrees to obtain and submit all hospice documents outling the care and responsibilites for R1 and all residents who recieve hospice services.
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Based on record review, LPAs did not observe a written plan care outlining R1's hospice care, specifically wound care. This posses an immediate health and safety risk to residents in care.
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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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4