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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610111
Report Date: 05/02/2023
Date Signed: 05/02/2023 03:11:16 PM


Document Has Been Signed on 05/02/2023 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LLCFACILITY NUMBER:
197610111
ADMINISTRATOR:ANDRANIK KAPIKYANFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 660-7742
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
05/02/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Andranik KapikyanTIME COMPLETED:
03:30 PM
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The purpose of this meeting was to discuss recent issues of non-compliance and the Administrators’ participation of an unlicensed facility, resulting in inappropriate transferring residents from this facility to the unlicensed facility. Present at today’s meeting were: Andranik Kapikyan, Applicant/Administrator; Grigor Kapikyan, Licensee, Regional Manager (RM) Angela Kendrick, Licensing Program Managers (LPMs), Eva Miller and Troy Agard and Licensing Program Analysts (LPAs) Melissa Ruiz, Angela Panushkina, and Michael Cava.

The informal conference process was explained to the Licensee and Administrator. Additionally, they were also informed that this Informal Conference is part of the administrative action process and that further non-compliance and/or citations would result in requiring the attendance at a Non-Compliance Conference meeting.

During today’s conference, the following matters were discussed:

On April 7, 2023, the Department received a complaint for California State Health Group, LLC. During the investigation, deficiencies were issued on 4/14/23 for which the Administrator had not submitted Plan of Corrections in a timely manner. LPA Miller discussed timely plan of corrections, proper eviction procedures, following facilities’ plan of operation, and the Administrator’s lack of knowledge regarding hospice regulations or procedures.

- On April 21, 2023, the Department received an Unlicensed Complaint allegation. It was alleged that a resident physically attacked another resident, causing Resident 1 (R1) injuries, resulting in hospitalization. The Unlicensed allegation was Substantiated on April 25, 2023 and a Notice of Violation of Law (NOVL) issued. At the time of the visit, the census was 6 of which 4 were transferred from California State Health Group LLC to the unlicensed by the Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/02/2023
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Licensee was asked what steps will be taken to prevent this from happening again. Administrator stated he will be resigning from his position and is actively looking for a new administrator. The licensee corroborated that statement.

Prior history of the citations and plan of corrections were discussed. Moving forward, the LPA will review submitted or missing Plan of Corrections for pending deficiencies and will communicate with the administrator if further is required.

The licensee and administrator were informed that the Regional Office will be communication with the Departments’ Legal Division to discuss possible further action. Exit interview conducted, a copy was provided.

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

DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023
LIC809 (FAS) - (06/04)
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