<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610144
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:53:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
08/21/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230821153401
FACILITY NAME:VICTORIA'S DIGNITY CAREFACILITY NUMBER:
197610144
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:13874 KELOWNA ST.TELEPHONE:
(818) 894-5761
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY:6CENSUS: 5DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
03:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents were signed up for hospice services without their knowledge.
Residents were signed up for hospice services without a physician's referral.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 8 :00 a.m. on 12/20/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with Staff #1 (S1) and later the administrator at approximately 8:30 a.m. and disclosed the reason for the visit.

Regarding the allegation “Residents were signed up for hospice services without their knowledge” it was alleged that the hospice consent forms of Resident #1 (R1) and Resident #2 (R2) were signed by facility staff S1 and Staff #2 (S2). To investigate the allegation, LPA reviewed pertinent records including but not limited to physician reports, preplacement appraisals, appraisals, needs and service plans, identification forms, Physician Orders for Life Sustaining Treatment (POLST) forms, hospice care plans, and hospice consent forms at 8:15 a.m., interviewed administrator and staff between 9:10 a.m. and 11:30 a.m., interviewed R1 at 10:00 a.m. and R2 at approximately 10:30 a.m., toured the facility at 10:00 a.m., and interviewed family members between 12:15 a.m. and 1:00 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
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-20230821153401
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VICTORIA'S DIGNITY CARE
FACILITY NUMBER: 197610144
VISIT DATE: 12/20/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Interview with the administrator revealed that R1’s family was not able to visit the facility to sign the hospice consent forms in person, so R1’s family authorized S1 to sign the form. Interview with S1 confirmed they had signed R1’s hospice form. S1 stated S2 did not sign any resident forms. Interview with S2 revealed they had not signed any resident forms. Interview with R1’s family revealed they did authorize the facility staff to sign R1’s hospice form. Interview with R2 revealed they did not recall whether they signed paperwork. Record review of R1 and R2’s revealed their hospice care plans were signed by a registered nurse, a medical social worker, a spiritual counselor, and a medical director, but were not signed by the licensee, R1, R2, or their responsible parties. Additionally, records detailing facility personnel duties, hospice visits, personnel trainings, and roommate acknowledgements were not maintained or available. These deficiencies are addressed on a separate LIC 809 – Case Management visit. R1’s hospice consent form was signed on 07/12/2022. The signature does not match R1’s signature. The box “Beneficiary is unable to sign” is checked. Hospice consent forms of R2 appeared to be signed by R2. R1’s POLST from 09/30/2020 and R2’s POLST from 06/16/2020 appeared to be signed by R1 and R2 as well. Based on interviews and record reviews, S1 signed R1’s hospice consent form. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on the attached LIC 9099-D page.

Regarding the allegation “Residents were signed up for hospice services without a physician's referral.” it was alleged R1 and R2 were enrolled in hospice services without a physician’s referral. Interview with the administrator revealed the facility was unable to arrange R1’s doctor’s appointment to obtain a referral. The administrator knew R1 had previously been enrolled in hospice, therefore the facility proceeded in assisting R1 in signing up for hospice services without the referral. Records revealed that R1 was previously enrolled in hospice services as of 10/14/2020. R1’s most recent hospice care plan indicated services began on 07/07/2023. R1’s most recent medical assessment on 08/18/2023 noted R1 was not enrolled in hospice services, and R1’s family signed forms discharging R1 from hospice on the same day. R2’s most recent medical assessment on 08/02/2023 noted R2 was enrolled in hospice services. Based on interview and record review, R1 did not have a physician’s referral for hospice services. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on the attached LIC 9099-D page.

No immediate health or safety hazards were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230821153401
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORIA'S DIGNITY CARE
FACILITY NUMBER: 197610144
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87633(a)(3)
1
2
3
4
5
6
7
87633 Hospice Care of Terminaly Ill Residents (a) The licensee shall... retain residents who... (3) Hospice agency services are contracted for by each terminally ill resident … not by the licensee on behalf of a resident. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Hospice services of Resident #1 (R1) were terminated on 08/18/2023. Licensee to conduct in-service training regarding the cited section and submit proof by the POC due date.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above in one (01) out of five (05) residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type B
12/29/2023
Section Cited
CCR
87633(h)(3)
1
2
3
4
5
6
7
87633 Hospice Care of Terminally Ill Residents (h) ... the licensee shall maintain the following in the resident’s record: (3)...the written certification statement of the resident’s terminal illness from... the individual’s attending physician
1
2
3
4
5
6
7
Hospice services of R1 were terminated on 08/18/2023. Licensee to conduct in-service training regarding the cited section and submit proof by the POC due date.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above in one (01) out of five (05) residents which poses a potential Health, Safety, or Personal Rights risk to persons 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3