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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 01/06/2022
Date Signed: 01/06/2022 01:27:48 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
01/04/2022 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20220104133027
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:
01/06/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility entrance is being restricted with a screw
Facility outdoor grounds poses as a risk to the residents while in care
Staff do not prevent the residents from accessing supplies while in care
Residents are denied from having access to the kitchen
Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegations.
During this investigation, LPA toured the facility at 9:00am and interviewed the facility administrator at 11:15am.

Allegation #1, that “Facility entrance is being restricted with a screw,” has been substantiated based on the reporting of a credible party as well as observations made and records reviewed. On 12/10/2021 the Long Term Care Ombudsman (LTCO), a credible reporting party, alleges that they arrived at the facility and observed staff 1 (S1) removing a screw from the front door frame before opening the door. S1 told the LTCO at the time of visit that the administrator of the facility instructed them to lock the door this way. A file review revealed that on 7/8/21 the facility was cited for this same action. On 1/6/22 at 10:37am LPA observed there to still be a hole in the bottom of the doorframe where the screw is alleged to have been used to lock the front door.
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: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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 4
Control Number 31-AS-20220104133027
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: 01/06/2022
NARRATIVE
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Allegation #2, that “Facility outdoor grounds poses as a risk to the residents while in care,” has been substantiated based on the reporting of a credible party as well as observations made by LPA. On 1/6/22 LPA arrived at the facility and at 9:18am observed numerous wooden fence posts with nails protruding to be scattered throughout the yard and back patio.

Allegation #3, that “Staff do not prevent the residents from accessing supplies while in care,” has been substantiated based on the reporting of a credible party and observations made by LPA. On 12/10/2021 the Long Term Care Ombudsman (LTCO), a credible reporting party, alleges that they observed the kitchen cabinets containing chemicals and medications to be unlocked and accessible to residents. On 1/6/22 at 9:16 am LPA observed the same cabinets to be unlocked and accessible to residents.

Allegation #4, that “Residents are denied from having access to the kitchen,” has been substantiated based on the reporting of a credible party and observations made by LPA. On 12/10/2021 the Long Term Care Ombudsman (LTCO), a credible reporting party, alleges that they observed the living room couches being used to block resident access to the kitchen area. On 1/6/22 at 9:15 am LPA observed the living room couches being used to block resident access to the kitchen area. Administrator stated that this was being done to help prevent residents with dementia from wandering into the kitchen and harming themselves.

Allegation #5, that “Facility is in disrepair,” has been substantiated based on the reporting of a credible party and observations made by LPA. On 12/10/2021 the Long Term Care Ombudsman (LTCO), a credible reporting party, alleges that they observed the frame of the facility’s front door to be damaged and altered in such a way that a screw could be inserted to lock the door in place. On 1/6/22 at 10:37 am LPA observed the above described modification to still be present at the bottom of the front door frame.

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: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220104133027
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: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited
CCR
80072(a)(7)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night.
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Administrator will conduct a training for all direct care staff instructing them not to lock the front door by any alternative means. Proof of training will be provided to LPA.
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This requirement is not met as evidenced by:

Based on the reporting of a credible party and observations made by LPA, the facility did not ensure that residents weren't locked into the facility which poses an immediate risk to residents in care.
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Type A
01/06/2022
Section Cited
CCR
87303(a)
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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator will provide proof of the wooden fence posts being removed from the backyard and patio, as well as the front door frame being repaired.
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This requirement is not met as evidenced by:
Based on LPA observations, the facility did not ensure that wood and nails from the previous backyard fence were disposed of, and did not ensure that the front door frame was repaired following the citation recevied on 7/8/21, 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: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220104133027
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: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2022
Section Cited
CCR
87705(f)(2)
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87705(f)(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants

This requirement is not met as evidenced by:
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Cabinets were secured on site. Administrator will provide proof of training to all direct care staff on this topic.
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Based on observations made by LPA on 1/6/22 at 9:15am, the facility did not ensure that kitchen cabinets containing cleaning supplies and medications were locked and inaccessible to residents with dementia, which poses an immediate risk to residents in care.
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Type B
01/17/2022
Section Cited
CCR
87307(d)(6)
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87307)(d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.



This requirement is not met as evidenced by:
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Administrator moved couches during visit, deficiency cleared on site.
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Based on observations made by LPA on 1/6/22 at 9:15 am, the facility did not ensure that the passageway between the dining room and the kitchen was free of obstruciton, 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: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4