197610123-12-28-2021-31-AS-NGID-CBBRCN-20220204115436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610123
Report Date: 12/28/2021
Date Signed: 12/28/2021 12:36:47 PM

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
12/27/2021 and conducted by Evaluator Patrick Shanahan

COMPLAINT CONTROL NUMBER: 31-AS-20211227095048

FACILITY NAME:	CONCORDIA ASSISTED LIVING		FACILITY NUMBER:	197610123
ADMINISTRATOR:	YEGEYAN, NAZAR		FACILITY TYPE:	740
ADDRESS:	16704 BLACKHAWK STREET		TELEPHONE:	(818) 403-1803
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	12/28/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nick Yegeyan		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not following COVID-19 guidelines.
Facility staff are unable to understand or communicate in English.
Facility does not provide a safe environment for residents in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned complaints. LPA was greeted by facility staff and explained the reason for the visit.

Allegation 1. Facility staff are not following COVID-19 guidelines
LPA arrived at the facility and staff (S1) opened the door. S1 was observed at 9:30 AM to not be wearing a mask. LPA walked into the home and into the kitchen and observed S2 preparing breakfast for residents. S2 was also not wearing a mask. The LPA reminded the staff that they must wear a mask and follow COVID-19 protocol at the facility at all times. S2 then took the LPA's temperature at about 9:45 am and had the LPA sign in at the front of the facility.
Based on LPA observation, this allegation is deemed to be substantiated at this time.

Continues on LIC 9099- C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

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-20211227095048

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: CONCORDIA ASSISTED LIVING	FACILITY NUMBER: 197610123
	VISIT DATE: 12/28/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation 2. Facility staff are unable to understand or communicate in English.
At 9:45 AM, LPA attempted to interview S1 and S2. LPA asked if the staff could provide the LPA with a staff roster or a resident roster and both staff indicated that they could not speak English. At about 10:15 AM, the LPA was then able to speak with residents at the facility. The first resident (R1)) indicated that the residents like the staff and that for the most part they are able to get their requests across to the staff. At 10:30 AM, the LPA was able to interview the administrator. The administrator indicated that he knows that this is problematic and that he has been working to get a staff member who speaks English at the property 24 hours a day.
Based on LPA observation and the administrator acknowledgement of the staff not being able to communicate effectively, this allegation is deemed substantiated.

Allegation 3. Facility does not provide a safe environment for residents in care.
At about 9:50 AM, LPA conducted a physical plant tour of the home. While touring the home, the LPA did not smell any signs of urine or other foul smells. There were no signs of immediate danger or any health and safety concerns. The LPA did observe that the staff were not following the COVID-19 protocols outlined in the facility mitigation plan that was submitted to Community Care Licensing (CCL). The LPA also observed that the staff were unable to communicate effectively in English to the residents, who all happen to be English speaking. Staff would also not be able to communicate effectively in the event of an emergency. Based on these observations and the administrators acknowledgement of these issues, this allegation is deemed substantiated.

Exit interview conducted, deficiencies cited and report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20211227095048

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: CONCORDIA ASSISTED LIVING	FACILITY NUMBER: 197610123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/29/2021 Section Cited CCR 87468.2(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on LPA observation, the administrator did not ensure that the COVID-19 protocal	1 2 3 4 5 6 7	The administrator agrees to hold an inservice on the facilities mitigation plan and submit a sign in sheet and teaching materials to the LPA by the POC date.
	8 9 10 11 12 13 14	was followed properly, which poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type B 12/31/2021 Section Cited CCR 87411(d)(3)	1 2 3 4 5 6 7	Personnel Requirements - General 87411(d)(3).. experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance.. Skill and knowledge required to provide necessary resident care and supervision,... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator has been actively looking for English speaking staff. Administrator agrees to put in writing his plan for hiring English Speaking staff and submit the plan by the POC date.
	8 9 10 11 12 13 14	Based on LPA interviews with staff and the administrators acknowledgment, the administrator did not have staff available to communicate with residents and emergency personnel effectively which poses a potential risk to the 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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3