197610111-1-27-2022-31-AS-EMIR-CJ3UGE-20220908153413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:23:06 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
01/21/2022 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20220121140830

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: 5	DATE:	01/27/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Armenui Simityan		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility failed to provide resident a proper notice for increase in rates
Facility staff threatened to illegally evict the resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced visit on this day in response to the above allegations.

During this investigation, LPA interviewed the complainant telephonically on 1/25/22; reviewed relevant client records and facility communication records on 1/26/22; conducted a facility visit on 1/27/22 at 10:30 am and interviewed the facility administrator and reviewed additional client records.

Allegation #1, that "Facility failed to provide resident a proper notice for increase in rates" has been substantiated based on the records reviewed and interviews conducted. On 1/27/22 the administrator provided LPA with a copy of the rate increase letters that were sent to Resident 1's (R1's) responsible party on 1/14/22 and 1/17/22. The first letter was dated 1/14/22 and states that the rate increase is due to "workforce and operational expenses" and that it is effective 1/14/22.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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 3

Control Number 31-AS-20220121140830

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: 01/27/2022

NARRATIVE

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The second letter is not dated, but states that the rate increase is due to the resident's "medical condition and level of care increase." It also states that the rate increase is effective 1/14/22, and lists two general changes in condition as the reason for the rate increase, but does not provide a detailed explanation of the additional services being provided nor a itemization of the charges.

Allegation #2, that "Facility staff threatened to illegally evict the resident," has been substantiated based on the licensee communication records reviewed by LPA on 1/26/22. Text messages between the licensee and R1's responsible party (RP) indicate that on 12/28/21 at 5:34pm, the licensee told R1's RP that "you should start looking for a place for [R1] to transfer [them] to." On 1/15/22 at 8:36am the licensee informed R1's RP that a rent increase letter had just been sent to R1. At 2:13pm on the same day, the licensee told RP that "if you don't respond i have to send a 24hr notice."

Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited on 9099D page.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20220121140830

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: 01/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/03/2022 Section Cited HSC 1569.657(a)	1 2 3 4 5 6 7	1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care.	1 2 3 4 5 6 7	Administrator will provide a signed statement of understanding and intent to abide by the cited regulation. If the administrator still intends to raise the rate for R1, then an appropriate notice will be sent to their RP and a copy will be provided to licensing as well.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on the interviews conducted and records reviewed, the facility did not ensure that an appropriately detailed rate increase letter was provided to R1's RP, which poses a potential risk to the personal rights of residents in care.	8 9 10 11 12 13 14
Type B 02/03/2022 Section Cited CCR 87224(a)(1)	1 2 3 4 5 6 7	87224(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5 (1) Nonpayment of the rate for basic services within ten days of the due date.	1 2 3 4 5 6 7	Administrator will provide a signed statement of understanding and intent to abide by the cited regulation. Administrator will also notify LPA in writing of their plan to either retain R1 as a resident of the facility, or issue a proper eviction notice.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: The facility did not ensure that R1 was given 10 days to pay their rent nor was R1 given 30 days notice of eviction which poses a potential risk to the health, safety or personal rights of residents in care.	8 9 10 11 12 13 14

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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC9099 (FAS) - (06/04)

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