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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610150
Report Date: 11/16/2021
Date Signed: 11/16/2021 11:10:03 AM

Unfounded


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
11/15/2021 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20211115131106
FACILITY NAME:CALIFORNIA DREAM ASSISTED LIVINGFACILITY NUMBER:
197610150
ADMINISTRATOR:AGHABEKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:7043 TAMPA AVETELEPHONE:
(818) 300-8393
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rima AgaronyanTIME COMPLETED:
11:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure a resident attended dialysis appointments while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Regarding the above allegation, it is alleged that the facility failed to bring R1 to scheduled dialysis appointments.

On 11/16/2021 at 10:30 AM, Licensing Program Analyst (LPA) Nicholas Reed met with Administrator for an unannounced complaint investigation. LPA disclosed the reason for the visit.

At 10:39 AM LPA conducted File Review. Admission Agreement showed R1 admitted on 11/01/2021. LPA also observed a handwritten note which stated "[R1] is refusing to go to Dialysis treatment". The note was signed by the Administrator and R1. At 10:47 AM LPA interviewed R1. LPA asked if R1 wanted to continue dialysis treatments. R1 shook head and replied “No”. To protect R1's personal rights, Administrator does not force R1 to attend dialysis appointments. Based on the information obtained through observation, interview, and records review, the above allegation is false, could not have happened, and/or is without a reasonable basis. Therefore the allegation is deemed unfounded. Exit interview conducted and report emailed to Administrator.
Unfounded
Estimated Days of Completion: 2
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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