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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:51:27 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
11/18/2021 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20211118163553
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: 5DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility does not assist resident with medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegation.

As part of today's visit, LPA toured the facility; interviewed the administrator, complainant and resident 1 (R1); reviewed R1's records, and attempted to contact R1's Home Health Agency.

Allegation #1, that "Facility does not assist resident with medication," has been substantiated based on the interviews conducted. At 12:30pm Administrator informed LPA that, prior to R1 being admitted to the hospital on 11/5/21, facility staff were measuring R1's blood glucose levels, but not administering their insulin. Administrator confirmed that facility staff, and not Home Heatlh, is currently measuring R1's glucose level and administering their insulin twice per day.
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: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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-20211118163553
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: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2021
Section Cited
CCR
87465(a)(1)
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87465(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
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Administrator will schedule for an appropriately skilled professional to conduct an assessment of R1 and provide staff training on assistance with self-administration of medication, if it is deemed appropriate by the skilled professional. If not, a plan will be submitted showing how R1's needs will be met.
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Based on interviews, the facility did not ensure that R1's medication was being given as prescribed 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: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3