197610150-6-18-2024-31-AS-NGID-D6KNJ8-20240625102956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610150
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:16:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
06/11/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20240611160853

FACILITY NAME:	CALIFORNIA DREAM ASSISTED LIVING		FACILITY NUMBER:	197610150
ADMINISTRATOR:	AGHABEKYAN, GAYANE		FACILITY TYPE:	740
ADDRESS:	7043 TAMPA AVE		TELEPHONE:	(818) 300-8393
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	06/18/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rima Agaronyan, Administrator Designee		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff are not meeting resident's hygiene needs.
Staff do not meeting resident's toileting needs.

INVESTIGATION FINDINGS:

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At 09:15 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced initial complaint visit. LPA met with Staff #1 (S1) who granted access to facility. The Designee was contacted and LPA explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 09:20 AM, LPA requested resident and staff roster. At 10:30 AM, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 9:40 AM, LPA conducted a physical plant tour. Between 10:00 AM – 12:15 PM, LPA conducted an interview with the Designee, one (1) staff, four (4) out of four (4) residents, and Resident #1 (R1’s) family member.

Continue on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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-20240611160853

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA DREAM ASSISTED LIVING	FACILITY NUMBER: 197610150
	VISIT DATE: 06/18/2024

NARRATIVE

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Staff are not meeting resident's hygiene needs:
It is being alleged that R1 did not receive a shower in about one week and a half (1½ ). To investigation this allegation, LPA conducted interviews with the Designee and one (1) staff, and both denied the allegation. LPA was informed that although R1 denies taking a shower occasionally, the facility still provides showers to R1 at least twice a week or as needed. Additionally, interview with R1’s family member confirmed the statement provided by the facility Designee and one (1) staff member. In addition, interviews with three (3) out of four (4) residents also revealed that they get showers at least twice a week. Moreover, during the interview with R1, LPA observed that R1 is well taken care of and appeared to be clean and well-groomed. There was no odor coming from R1. Based on interviews and LPA’s observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Staff do not meeting resident's toileting needs:
It was alleged that staff left R1 on the toilet chair for an extended time which left R1 in pain. To investigate this allegation, LPA conducted an interview with S1 who denied the allegation. Staff informed LPA that they are always available to assist and check on R1 regularly while in the bathroom. Additionally, interview with the Designee revealed that R1 has a portable call button that R1 can carry everywhere and press for an assistance anytime. Once the call is activated, the staff provides an immediate assistance. LPA inspected the portable call button and observed it to be functional/operational. Lastly, interviews with three (3) out of four (4) residents confirmed that the facility staff always assist residents with incontinent and toileting needs and the residents are very pleased with the care provided. Moreover, interview with R1’s family member revealed that R1 takes extended period of time on the toilet chair due to the constipation and did not express any concerns regarding this allegation.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

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