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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 11/16/2021
Date Signed: 11/16/2021 03:44:19 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
11/12/2021 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20211112154824
FACILITY NAME:VELVET CAREFACILITY NUMBER:
197610143
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:15731 LEMARSH ST.TELEPHONE:
(818) 891-9186
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility is neglecting resident's needs
Facility is not providing clean linens
Facility failed to provide timely medical assistance
Facility staff are unable/unqualified to respond to emergency response personnel
Facility is malodorous
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegations.
On 11/12/21 LPA interviewed the complainant telephonically, and on 11/16/21 conducted a visit to the facility to interview the administrator, staff 1 (S1), staff 2 S2), Resident 1 (R1).
Allegation #1, that “Facility is neglecting resident's needs,” has been substantiated based on the interviews conducted. On 11/12/21 LPA was informed by the complainant, a credible party, that on 11/5/21 they observed R1 to be left in “deplorable conditions” and appeared as though they “had not been helped once since moving in.” On 11/16/21 at 11:30am LPA reviewed R1’s physician’s report and confirmed that R1 is incontinent of both bowel and bladder. At 12:11pm on 11/16/21, the administrator stated there was no professionally developed incontinence care plan on file for R1 or any other resident. At 12:15pm on 11/16/21, Administrator confirmed that R1 is diabetic, and unable to test their blood sugar or administer insulin.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 5
Control Number 31-AS-20211112154824
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: VELVET CARE
FACILITY NUMBER: 197610143
VISIT DATE: 11/16/2021
NARRATIVE
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Administrator stated that staff are performing these functions and stated that he knew this was not permitted under Title 22 regulations. At 12:18pm on 11/16/21 Administrator stated that R1 was “too weak” to care for their catheter and confirmed that there was no written documentation that an appropriately skilled professional had provided training to staff on how to care for it.

Allegation #2, that “Facility is not providing clean linens,” has been substantiated based on the reporting of a credible party. On 11/12/21 LPA was informed by the complainant that on 11/5/21 R1 was observed to be laying in sheets that had obviously been stained over time, some of which were “saturated” in urine and feces.

Allegation #3, that “Facility failed to provide timely medical assistance,” has been substantiated based on the interviews conducted. On 11/12/21 LPA was informed by the complainant, a credible party, that on 11/5/21 they found R1 unresponsive at the facility due to being hyperglycemic. Complainant stated that they were informed by the administrator that he had checked R1’s blood sugar approximately 15 minutes before calling 911 and that R1 was lethargic at that time. On 11/16/21 at 12:30pm Administrator informed LPA that R1’s blood sugar had not been checked prior to finding R1 unresponsive and calling 911.

Allegation #4, that “Facility staff are unable/unqualified to respond to emergency response personnel,” has been substantiated based on the reporting of a credible party. On 11/16/21 the complainant informed LPA that on 11/5/21 they responded to the facility to assist R1, and the administrator was asked a series of questions pertaining to what R1’s needs were and who was responsible for meeting them, to which the administrator failed to respond.

Allegation #5, that the “facility is malodorous,” has been substantiated based on the interviews conducted and observations made. On 11/12/21 LPA was informed by the complainant that on 11/5/21 the facility smelled strongly of urine and feces. On 11/16/21 at 9:00am LPA arrived at the facility and observed a strong smell of urine and feces in the air throughout the facility.

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

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20211112154824
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: VELVET CARE
FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2021
Section Cited
CCR
87411(a)
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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance
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Administrator will provide an LIC500 showing adequate staff coverage, as well as proof of a professionally developed incontince care plan and catheter care plan being developed for all relevant residents, as well as a plan on how to meet R1's diabetic needs.
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This requirement is not met as evidenced by:
Based on interviews conducted, the facility did not ensure that facility staff were qualified enought and suffient in quantity to ensure that R1's incontinence, diabetes, and catheter were being appropriately cared for which poses and immediate risk to residents in care.
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Type A
11/17/2021
Section Cited
CCR
87465(g)
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87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Administrator will provide a signed statement of understanding and intent to abide by the cited regulation.
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This requirement is not met as evidenced by:

Based on interviews, the facility did not immediately call 911 after finding that R1 was lethargic and unresponsive on 11/5/21 which poses an immediate risk to 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: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20211112154824
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: VELVET CARE
FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2021
Section Cited
CCR
87405(d)(1)
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87405(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Administrator will conduct a review of all residents' care plans, and provide copies of updated needs and services plans for all residents.
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This requirement is not met as evidenced by:

Based on interviews, the administrator did not ensure that they were familiar enough with the needs of R1 and their responsiblities to respond to emergency response personnel which poses an immediate risk to residents in care.
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Type B
11/23/2021
Section Cited
CCR
87307(a)(3)(C)
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(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean
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Administrator will provide a signed statement of understanding and intent to abide by the cited regulation.
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This requirement is not met as evidenced by:

Based on the reporting of a credibly party on 11/5/21 the facility did not ensure that clean linens were provided to R1 which poses a potential risk to 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: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20211112154824
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: VELVET CARE
FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2021
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.




This requirement is not met as evidenced by:
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Administrator will provide a signed statement of understanding and intent to abide by the cited regulation, as well as proof of a professionally developed incontinence care plan being implemented and staff trained.
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Based on observations and interviews, the administrator did not ensure that the facility remained free of odors from incontinence which poses a potential risk to 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: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5