197610143-11-30-2021-31-AS-EMIR-CHRN8K-20220829101424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:24:45 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
11/23/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20211123084945

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: 5	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Jack Berghoudian		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff administered injections to resident in care
Staff is not fingerprint cleared
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.

As part of this investigation, LPA interviewed the complainant on 11/23/21, the administrator on 11/30/21 and 11/16/21, and toured the facility.

Allegation #1, that "Staff administered injections to resident in care," has been substantiated based on the interview conducted with administrator on 11/16/21. At 12:15pm on 11/16/21, Administrator confirmed that Resident 1 (R1) is diabetic, and unable to test their blood sugar or administer insulin. Administrator stated that staff are performing these functions and stated that he knew this was not permitted under Title 22 regulations.

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: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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-20211123084945

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: 11/30/2021

NARRATIVE

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Allegation #2, that "Staff is not fingerprint cleared" has been substantiated based on interviews conducted and files reviewed. On 11/23/21 the facility was cited for Staff 1 (S1) not having background clearance and civil penalties were issued. The allegation is substantiated, but no additional citations are being issued on this day as the deficiency has been corrected.

Allegation #3, that "Facility is in disrepair," has been substantiated based on the observations made by LPA on 11/16/21 at 11:11am. On that day the facility was cited for the side fence being in disrepair. The allegation is substantiated, but no additional citations are being issued on this day as the fence has been repaired.

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

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20211123084945

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: 11/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/07/2021 Section Cited CCR 87628(a)	1 2 3 4 5 6 7	(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through...	1 2 3 4 5 6 7	Administrator will obtain and provide proof of training on restricted health conditions from an approved vendor. The medications in question have been discontinued and R1 is not facing any immediate neglect.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, the facility did not ensure that R1's diabetes medication and testing was done by themself or an appropriately skilled professional 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: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3