197610143-10-7-2022-31-AS-EMIR-CKYQZR-20221108113711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 10/07/2022
Date Signed: 10/07/2022 02:11:49 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
11/18/2021 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20211118163553

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:	10/07/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Naira Paroyan		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff do not follow resident's care plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Evelin Rios and Michael Cava made an unannounced subsequent visit to complete the investigation of the allegation above. LPA met with facility staff and explained the reason for this visit.

Regarding the allegation, staff do not follow resident’s care plan it is alleged, R1 is not being rotated every 2 hours as ordered. An investigation previously done (Control #31-AS-20211112154824) where it was substantiated “facility is neglecting resident's needs” based on interviews conducted by LPA Alexander Pitz on 11/12/21 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 Pitz 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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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-20211118163553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
	VISIT DATE: 10/07/2022

NARRATIVE

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LPA Rios reviewed R1’s physician report on 09/09/2022 and confirmed LPA Pitz finding, R1 was bowel and bladder incontinent. On 09/30/2022, LPA Rios confirmed with the Administrator there was no professionally developed incontinence care plan on file for R1. LPA Rios reviewed R1’s appraisal/needs and services plan and confirmed caretakers need to rotate R1 every 2 hours when he is in bed.
Based on the information obtained through interviews and files review during previous complaint investigations and interviews and file review for this investigation this allegation is deemed Substantiated.
Citations were issued on 11/16/2021 by LPA Pitz, and cleared on 11/16/2021 no additional citations are to be issued at this time. Exit interview conducted and a copy of this report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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