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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610248
Report Date: 12/15/2025
Date Signed: 12/15/2025 12:51:56 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.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
05/03/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240503115353
FACILITY NAME:VELVET CAREFACILITY NUMBER:
197610248
ADMINISTRATOR:PAROYAN, NAIRAFACILITY TYPE:
740
ADDRESS:15731 LEMARSH ST.TELEPHONE:
(818) 810-0074
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
12/15/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Naira Paroyan- AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Due to neglect, resident received skin tears and multiple pressure injuries.
Staff are not following Hospice Care Plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with administrator Naira Paroyan and explained the reason for the visit.

On 05.03.2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint alleging, “Due to neglect, resident received multiple pressure injuries.” The complainant was alleging that resident #1 (R1) arrived at the hospital with multiple pressure injuries, some Unstageable. R1 was in ICU as of 05/02/24.

The complaint was referred to Community Care Licensing Division’s Investigations Branch (CCLD IB). The referral was accepted and assigned to Senior Investigator (SI) Christine Ferris.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
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 5
Control Number 31-AS-20240503115353
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: VELVET CARE
FACILITY NUMBER: 197610248
VISIT DATE: 12/15/2025
NARRATIVE
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On 05.06.2024 LPAs Ngo-Castaneda initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but are not limited to R1’s Physician’s Report, Admission Agreement, Resident Appraisal, Needs and Service Plan dated 10.28.2023 and other records related to the complaint allegation. LPA conducted interviews with the Administrator and three (3) out of six (6) residents, who were able to communicate.

On 6.5.2024 SI Ferris conducted interview with, administrator; Staff #1 (S1) at 11:30AM, staff #3 (S3) at 12:00 PM, staff #2 (S2) at 1:30PM, resident #3 (R3) at 2:30PM, resident #6 (R6) at 2:45PM, resident #4 (R4) at 3:00PM, resident #1 (R1) at 3:30PM. Wound specialist was interviewed on 7.2.2024 at 8:30AM. Between 7.11.2024 and 07.23.24 hospice nurses, hospital social worker and nurses were interviewed. On 06/12/24 SI Ferris reviewed R1 medical records from hospice and hospital. (The records were subpoena on 05/16/24)

Allegation#1: Due to neglect, resident received skin tears and multiple pressure injuries.

The investigation revealed that R1 had been living at this facility since 10.28.2023. Upon R1’s admission to the facility, R1 was noted to have infection and inflammatory reaction and other complicated health conditions. Per assessment records from hospice, on 10/28/23 at the time of admission to the facility, R1 had stage 2/3 wounds. The Administrator and staff have knowledge of R1’s health conditions and complications. Staff revealed that they were not aware of R1 having skin tears. R1 was private person and was able to care for their ADL including bathing, and toileting. Although facility staff were advised by hospice nurses how to assist R1 when hospice was not present, staff relied on wound care specialists and hospice nurses assuming that they were providing care that R1 needed.

A review of facility records revealed that R1 was receiving Hospice services which was initiated prior to R1’s admission to the facility. Between 08/21/23 and 05/01/24 R1 was receiving wound care services by wound care specialists, visiting R1 once a week. A review of the hospice visits and wound care notes, between 01/24/2024 through May 1, 2024, revealed that “R1 needed maximum assistance with all activities of daily living. (ADL) which included standing with maximum support. Required assistance communicated to the caregiver. The caregivers were also reminded “to reposition the resident every two hours to prevent pressure ulcers and to “promptly notify hospice of any concerning changes in the patient`s condition…”
Continue to LIC 9099-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20240503115353
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: VELVET CARE
FACILITY NUMBER: 197610248
VISIT DATE: 12/15/2025
NARRATIVE
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On 04/05/24 the wound care specialist identifies a second wound as a “new vascular stasis ulcer” which takes longer to heal. Between 04/05/24 and 04/30/24 wound care visit report identified that both wounds were not healing. On 05/01/24, R1 had nose bleeding for 3 days and leg bleeding.

On 05.02.2024, R1 was admitted to the hospital with knee wound bleeding, unstageable pressure Injury and Stage 3 Pressure Injuries on right and left posterior thighs.

Overall investigation revealed that R1 was admitted to the facility with complicated health conditions and stage 3 pressure injury with large amount of drainage. While R1 continued to remain in the facility, conditions(s) of the pressure injuries were worsening. Although hospice nurses and wound care specialists were responsible for providing wound care, staff failed to follow instructions received from the health care professionals to provide required assistance and reposition R1 every two (2) hours.

Based on the interviews and record review, the facility admitted and retained R1 with prohibited health conditions and failed to assist R1 as per instructions received by medical professionals. Staff also failed to seek medical attention in a timely manner when R1’s condition was worsening. Therefore, the allegation is Substantiated at this time.

Allegation #2: Staff are not following Hospice Care Plan

It was alleged that facility staff are not following hospice care plan. Interview with staff revealed that they did not assist R1 with ADLs and did not touch or assist R1 with repositing since R1 did not want to be touched. Staff rely on medical personnel to provide required care for R1.

A review of R1’s hospice records conducted by the LPA Ngo-Castaneda on 12/06/25 revealed that facility staff were instructed to rotate and reposition R1 every two (2) hours. Per hospice records “Patient (R1) needed maximum assistance with all activities of daily living (ADLs) which included standing with maximum support. Required assistance communicated to the caregiver. The caregivers were also reminded to reposition the resident every two hours to prevent pressure ulcers and to “promptly notify hospice of any concerning changes in the patient`s condition…”

Continue to LIC 9099-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240503115353
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: VELVET CARE
FACILITY NUMBER: 197610248
VISIT DATE: 12/15/2025
NARRATIVE
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Based on the information obtained during the course of the investigation the allegation is deemed substantiated at this time.

The following deficiencies were issued and recorded on LIC9099D.

Licensee was informed that an immediate Civil Penalty of $500.00 will be issued to the facility at the time of this visit. Additional civil penalty maybe be assessed at later time based on Health and Safety Code 1569.49


Exit interview was conducted. Appeal rights discussed and a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240503115353
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: VELVET CARE
FACILITY NUMBER: 197610248
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2025
Section Cited
CCR
87615(a)
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Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
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The administrator will ensure the facility shall not admit/retain persons a prohibited health condition which require health services including, but not limited to Stage 3 and 4 pressure injuries. Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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This requirement is not met as evidenced by; The licensee admitted and retimed R1 with Stage 3 Pressure injuries. This poses an immediate health and safety risk to residents in care.
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 An immediate penalty of $500 shall be assessed of R1.
Type A
12/16/2025
Section Cited
CCR
87464(d)
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A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs…
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The Administrator will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to 87464(d) All proof must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by. The licensee did not follow specific instructions to assist R1 as provided by the health care professionals. This poses an immediate health and safety risk 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5