197610143-11-2-2021-31-AS-MVAO-CD9TV2-20220407150313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610143
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:42:46 PM

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
10/27/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20211027124121

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:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jack Berghoudian		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Unqualified staff administering medications to residents in care.
Resident needs are not met due to staffing shortage.

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 a relevant witness telephonically on 11/1/21, and conducted a site visit on 11/2/21 at 9:00am where the administrator and staff 1 (S1) were interviewed and relevant facility records were reviewed.
Allegation #1, that "Unqualified staff administering medications to residents in care" has been substantiated based on the interviews conducted and observations made. S1 stated that their training on passing medications consisted of a brief explanation from the outgoing staff member about when to give AM vs PM medications. At 11:00am LPA asked the administrator for proof of S1's training and was given a one page paper that listed hours for various topics, including 6 for medications, but did not specify the day the training was given or by whom. At the time of this visit S1 is the only caregiver employed by the facility, the allegation is substantiated.

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: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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-20211027124121

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: 11/02/2021

NARRATIVE

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Allegation #2, that "Resident needs are not met due to staffing shortage," has been substantiated based on the observations made, interviews conducted and records reviewed. Both S1 and the administrator confirmed that S1 is currently the only caregiver working at the facility and caring for its six residents. S1 reported having to provide supervision to residents, including bathing, laundry, cooking and cleaning. LPA observed four residents to have diagnosis of dementia and S1 reported that two require extensive assistance with eating. LPA observed Resident 1 (R1) and Resident 2 (R2) to have recent injuries related to falls that S1 said occurred because they weren't being supervised. During LPAs tour of the facility which began at 9:00am LPA noticed a consistent odor of urine and feces in client rooms. LPA observed R1 walking around with soiled clothing from approximately 9:00am until 10:45am. The allegation is substantiated.

Report reviewed, signed and delivered. Exit interview conducted, citations issued on 9099D page. A subsequent CM visit was conducted to address additional deficiencies observed during this visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20211027124121

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: 11/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2021 Section Cited HSC 1569.69(a)(2)	1 2 3 4 5 6 7	2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other...	1 2 3 4 5 6 7	Administrator will provide proof of required medication training being provided by a certified vendor.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and records reviewed, the facility did not ensure that staff were properly trained before assisting residents with self-assistance of medication which poses an immediate risk to residents in care.	8 9 10 11 12 13 14
Type A 11/03/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(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 personal...	1 2 3 4 5 6 7	Administrator will provide LPA with an LIC500 staff schedule that shows adequate staff coverage for the facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, observations and records reviewed the facility did not ensure that there is sufficient staffing to meet the residents needs which poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14

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: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

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