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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 07/07/2022
Date Signed: 07/07/2022 01:52:16 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
07/01/2022 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20220701112532
FACILITY NAME:CALIFORNIA STATE HEALTH GROUP LLCFACILITY NUMBER:
197610111
ADMINISTRATOR:SIMITYAN, ARMENUIFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 660-7742
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Andranik KapikyanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Sidegate has padlock
Licensee failed to report incident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPAs met with the administrator, Andranik Kapikyan and advised him of the allegations. During the course of the investigation, LPAs conducted interviews and a plant inspection.

Sidegate has padlock:
In regards to the allegation, the Licensing agency received information that the facility's side gate is locked. LPAs conducted an inspecetion of the home and observed a swimming pool, with a five foot fence gated and locked around it's parameters. Also during the plant inspection, LPAs did observe a padlock on the side gate of the home. Although the sidegate does not serve as a direct exit, review of the facility's fire clearance (STD 850), does not indicate that the use of the padlock at the side gate was permitted. Therefore, base on this observation, the allegation of the sidegate has padlock is Substantiated. Citation issued on the 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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 5
Control Number 31-AS-20220701112532
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: 07/07/2022
NARRATIVE
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Licensee failed to report incident:
In regards to the allegation, the Licensing agency received a report alleging that on or around 6/15/22, Resident 1 (R1) wandered away from the facility. Interview with the administrator, confirms that R1 did AWOL on or around 6/15/22. Administrator stated they reported the incident to Local Law Enforcement, and R1 was returned to the facility with no injuries or change in condition. The administrator also admitted that they did not report the incident to the Licensing agency as required pursuant to regulation 87211 Reporting Requirements. Therefore, based on this admission, the allegation is Substantiated. Citation issued on the 9099D.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20220701112532
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: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited
CCR
87468.1(a)(6)
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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement has not been met
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During the day's investigation, the administrator removed the lock. No further corrections required.
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as evidenced by the LPAs observing the sidegate being locked with a padlock. Although this gate doesn't serve as a direct exit, this may pose an immediate health and safety risk for the residents in care.
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Type B
07/14/2022
Section Cited
CCR
87211(a)(1)(D)
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained
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As POC, the administrator will review this section of the regulation and self- certify that they read and understood this section of the regulation. Written self-certification is due to the licensing agency no later than 7/14/22.
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absence of any resident. This requirment has not been met as evidenced by the administrator's admission that an Incident Report was not filed with the Licesing Agency. This may pose a potential health and safety risk for the 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/01/2022 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20220701112532

FACILITY NAME:CALIFORNIA STATE HEALTH GROUP LLCFACILITY NUMBER:
197610111
ADMINISTRATOR:SIMITYAN, ARMENUIFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 660-7742
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Andranik KapikyanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Staff are not properly trained.
Medical equipment is in disrepair.
Staff utilize step ladder up against door to prevent residents from leaving
Insufficient staffing
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPAs met with the administrator, Andranik Kapikyan and advised him of the allegations. During the course of the investigation, LPAs conducted interviews and a plant inspection.

Staff are not properly trained:
In regards to the allegation, it was reported to the Licensing agency that newly hired staff have not received the required initial training. Interviews with staff reveal that their initial training has been met. Review of facility records also confirms that staff training was initiated. 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20220701112532
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: 07/07/2022
NARRATIVE
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Medical equipment is in disrepair:
In regards to the allegation, it was reported that Resident 2 (R2) glucometer wasn´t working. During the course of the visit, LPAs inspected R2's glucometer and observed it to be operational. According to the administrator, this glucometer has been with R2 since their admission. There was never any problems with the device. Based on the information obtained, there was insufficient evidence to corroborate the allegation of R2's medical equipment is in disrepair. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff utilize step ladder up against door to prevent residents from leaving:
In regards to the allegation, it was reported that staff would place a step ladder on the front door to prevent residents from leaving facility. Interviews with residents do not corroborate with the allegation. Furthermore, LPAs conducted an inspection of the physical plant and did not observe a step ladder near the exit doors. Therefore, based on the information obtained, the allegation of staff utilizing a step ladder to prevent residents from leaving the facility is deemed Unsubstantiated at this time.

Insufficient staffing:
In regards to the allegation, the Licensing agency received information that there were only two staff scheduled to work at the facility. During the LPA's investigation, two staff and the administrator were observed at the facility providing elements of care and supervision. According to the administrator, he has two staff on duty at all times. Administrator stated facility also has one reliever, and he comes to the facility so often to overlook the facility operations. LPAs interviewed residents, who indicated facility has sufficient staffing and their needs are met. Based on the information obtained, there was insufficient evidence to corroborate the allegation. Therefore the investigation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5