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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610227
Report Date: 01/25/2023
Date Signed: 01/25/2023 03:51:36 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
10/24/2022 and conducted by Evaluator Joscelyn Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221024085852
FACILITY NAME:GARDEN GROVE ASSISTED LIVING, INCFACILITY NUMBER:
197610227
ADMINISTRATOR:GASPARYAN, ANNAFACILITY TYPE:
740
ADDRESS:8525 GARDEN GROVE AVENUETELEPHONE:
(747) 243-7965
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 5DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:sona gevorkyanTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff are not releasing resident's records in a timely manner.
INVESTIGATION FINDINGS:
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On 01/25/23 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival LPA met with Sona Gevorkyan and the purpose of the visit was conducted.

Allegation: Staff are not releasing resident's records in a timely manner.

It is alleged that the facility did not provide the documents to R1’s Long Term Care Insurance upon written notice. LPA interviewed R1 and stated that the facility did not provide the documents the insurance was requesting which resulted in R1’s claim being closed. Interview with S1 stated they had faxed over some documents to the requestor but did not have a confirmation date nor date in where the documents were faxed. Interview with S2 stated that the documents were sent to the requestor a week after LPA conducted an initial visit on 10/31/22. LPA obtained a copy of the letter request that was provided to the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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-20221024085852
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: GARDEN GROVE ASSISTED LIVING, INC
FACILITY NUMBER: 197610227
VISIT DATE: 01/25/2023
NARRATIVE
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According to document review, the initial request was sent on 07/29/22 and the second request was sent on 09/07/22. Due to observation and interview this allegation is deemed Substantiated. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited

Exit interview conducted. Report signed and delivered. Appeal rights delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20221024085852
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: GARDEN GROVE ASSISTED LIVING, INC
FACILITY NUMBER: 197610227
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2023
Section Cited
CCR
87468.2(a)(19)
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 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.
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Plan of correction was cleared during the visit. R1 stated they did not want to reopen their claim and did not want the facility to assist in re-opening the claim.
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This requirement was not met as evidenced by:
Based on interviews and document review facility did not provide required paperwork to requestor which poses an potential health and
safety risk or personal rights 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3