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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610255
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:45:58 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.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
09/21/2022 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20220921151917
FACILITY NAME:AMAZING SENIOR CARE ON LASSEN, INC.FACILITY NUMBER:
197610255
ADMINISTRATOR:ALADADYAN, YELENAFACILITY TYPE:
740
ADDRESS:17127 LASSEN STTELEPHONE:
(818) 207-4220
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 6DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Yelena Aladadyan - AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not meet a resident's diabetic needs while in care

Staff are not meeting a resident's incontinence needs while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with administrator Yelena Aladadyan and explained the reason for the visit.

LPA conducted physical plant tour at 10:20 AM, requested copies of facility documents relevant to the investigation at 10:45 AM and interviewed staff and resident between 11:00 AM to 1:00 PM. LPA also conducted record review between 1:00 PM to 2:00 PM. Regarding the allegation that Staff did not meet a resident's diabetic needs while in care, it was alleged that Resident #1 (R1) was given sugar filled diet (i.e., donuts) and R1 was diabetic. LPA's record review today revealed that R1 was on diabetic diet since admission. LPA's interview with another diabetic resident (R2) today at 11:02 AM revealed that the staff are very careful on R2's diet and was not given anything that might affect R2. R2 and three (3) other aware residents interviewed denied being served doughnuts nor witnessed R1 being served doughnuts when R1 was still at the facility. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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 2
Control Number 31-AS-20220921151917
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: AMAZING SENIOR CARE ON LASSEN, INC.
FACILITY NUMBER: 197610255
VISIT DATE: 11/30/2023
NARRATIVE
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(continued from LIC 9099)

Regarding the allegation that Staff are not meeting a resident's incontinence needs while in care, it was alleged that R1 had incontinence associated Dermatitis and not cleaned while living at the facility. LPA's record review today at 1:00 PM revealed that R1 was admitted at the facility on 07/01/22. On 07/02/22, R1 was admitted for a Hospice services and on the same day of admission, Hospice nurse trained the staff on how to care for R1's wounds including but not limited to turning, hydration and incontinent needs to avoid infection and skin tear. LPA's interview with three (3) incontinent residents today between 11:00 AM to 1:00 PM revealed that all three (3) of the residents interviewed were being checked every two (2) hours or less, regularly changed diapers between four (4) to five (5) times a day by the staff. All the three (3) incontinent residents added that staff are very attentive and takes good care of them and their care needs.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2