197610111-6-21-2023-31-AS-TAGD-CV6U3N-20230829151347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 06/21/2023
Date Signed: 06/21/2023 01:30:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
01/28/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20220128164153

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: 6	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Andranik Kapikyan - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Lack of care and supervision led to resident injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met initially met with staff Liana Gafikyan who called the administrator. Administrator Andranik Kapikyan arrived in about twenty (20) minutes. LPA explained the reason for the visit.

LPA conducted physical plant tour at 9:40 AM, requested copies of facility documents relevant to the investigation at 10:00 AM and interviewed staff and residents between 10:10 AM to 12:00 PM. Regarding the allegation that Lack of care and supervision led to resident injury, it was alleged that Resident #1 (R1) sustained bruising to the face after a fall. LPA's record review revealed that R1 had the capacity for self care including but not limited to bathing, dressing and toileting. LPA's interview with staff who is still employed when R1 was here today at 11:30 PM, revealed that R1 was able to ambulate on R1's own and never had any fall when the staff was on duty. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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-20220128164153

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA STATE HEALTH GROUP LLC	FACILITY NUMBER: 197610111
	VISIT DATE: 06/21/2023

NARRATIVE

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(continued from LIC 9099)

Further review also revealed R1 was assessed to be able to walk at the facility with no assistance and did not use walker while in the facility. There was no indication that R1 was a fall risk while living at the facility. Moreover, Centrally Stored Medication and Destruction Record (CSMDR) review also revealed that R1 was never prescribed Seroquel. LPA's interview with the administrator today at 11:03 AM revealed that R1 fell outside of the facility with a family member who took R1 out of the facility despite the advise against it.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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