197610111-7-19-2024-31-AS-NGID-D7VMBW-20240806092835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 07/18/2024
Date Signed: 07/19/2024 10:44:02 AM

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
07/12/2024 and conducted by Evaluator Leslie Ngo-Castaneda

COMPLAINT CONTROL NUMBER: 31-AS-20240712144416

FACILITY NAME:	CALIFORNIA STATE HEALTH GROUP LLC		FACILITY NUMBER:	197610111
ADMINISTRATOR:	ANDRANIK KAPIKYAN		FACILITY TYPE:	740
ADDRESS:	9526 SALOMA AVE		TELEPHONE:	(818) 810-9339
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Isaiah Phiri		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a initial complaint visit to the facility to investigate the above allegations. LPA met with designee staff member Isiah Phiri and was advised about the visit. Administrator was not available; staff called administrator and advised the reason of the visit over the phone.

An entrance interview was conducted.

Today's investigation involved interviews with the administrator, staff, and residents. LPA also conducted a physical plant inspection of the facility at 8:40 AM to ensure the health and safety of the residents and a review of records. At 9:33 AM, LPA requested the resident and staff roster. During the investigation, interviews and record reviews were made.

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: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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-20240712144416

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: 07/18/2024

NARRATIVE

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At 9:40 AM, LPA requested copies of pertinent information which include, but are not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan/Individual Program Plan (IPP), LIC 500, LIC 9020 and documents relevant to the investigation. Between 8:32 AM to 9:34 AM, LPA interviewed the Administrator over the phone, two (2) staff, and five (5) residents.

Allegation: Staff did not treat resident with dignity and respect

Regarding the allegation, it was alleged that on July 12, 2024 (Friday) at 11:30AM in the living room of the facility, the licensee was harassing and retaliating against Resident #1 (R1) regarding a rent increase beginning September 12, 2024. R1 advised LPA that they have been paying the same rate of $550 for a year and a half (1.5 years). LPA receive a copy of sixty (60 )-day notice regarding rate increase and not an eviction letter. There was one (1) staff and three (3) resident witnesses identified to confirm these allegations were not true. Furthermore, four (4) out of five (5) of the residents also deny the allegations, with several residents stating staff and administrator treats them cordially and speak to them respectfully. Based on the information, there was insufficient evidence to corroborate the allegations of the licensee not treating residents with respect, or the licensee harassing and retaliating at residents. Therefore, the allegation is deemed unsubstantiated at this time.

The administrator advised and a copy of this report was issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

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