197610143-1-11-2022-31-AS-EMIR-CHNV7A-20220826161049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 01/11/2022
Date Signed: 01/11/2022 12:45:54 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
01/07/2022 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20220107142101

FACILITY NAME:	VELVET CARE		FACILITY NUMBER:	197610143
ADMINISTRATOR:	BERGHOUDIAN, JACK J		FACILITY TYPE:	740
ADDRESS:	15731 LEMARSH ST.		TELEPHONE:	(818) 891-9186
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	01/11/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Narine Malinstyan		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not adequately supervise resident in care.

INVESTIGATION FINDINGS:

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2
3
4
5
6
7
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9
10
11
12
13

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

During this investigation LPA attempted to contact the complainant on 1/10/22; interviewed the administrator and reviewed relevant facility records on 1/11/22 at 11:30 am.

Allegation #1, that "Facility staff did not adequately supervise resident in care," has been substantiated based on the interviews conducted and records reviewed. Administrator confirmed that on 1/6/22, from approximately 3:30pm- 5:30pm, Resident 1 (R1) left the facility unnoticed and had to be returned to the facility by police. Administrator also confirmed that R1 has a diagnosis of dementia and is not permitted to leave the facility unsupervised.
Report reviewed, signed and delivered. Exit interview conducted, deficiency cited on 9099D page.

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: 01/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

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-20220107142101

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: 01/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/18/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(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...	1 2 3 4 5 6 7	Administrator will provide proof of training being obtained by all staff from an approved vendor on the topic of dementia care and elopment risks. Administrator will also provide a record of actual staff hours worked and scheduled for the month of July.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not ensure that there were a sufficient number of qualified staff present to prevent R1 from eloping from the facility which poses an immediate risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

LIC9099 (FAS) - (06/04)

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