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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610255
Report Date: 11/01/2023
Date Signed: 11/01/2023 11:58:23 AM

Substantiated


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:
11/01/2023
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Yelena Aladadyan - AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not ensure a resident was hydrated while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with Administrator Yelena Aladadyan and explained the reason for today’s visit.

During the initial visit on 09/22/22 at 9:50 AM, LPA Martinez obtained copies of facility documents relevant to the investigation. This complaint was referred to the Investigation Bureau (IB) on 09/20/22 and was assigned to IB Investigator Dennis Douglas. Investigator Douglas interviewed family members and partner of R1 on 10/06/22 and 12/29/22, facility administrator, licensee, staff and residents of the facility on 10/14/22 and hospice nurses, wound nurses and hospital doctor and nurses on various dates from 10/14/22 to 01/31/23.

(continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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 6
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: 11/01/2023
NARRATIVE
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(continued from LIC 9099)

Regarding the allegation that staff did not ensure that resident was hydrated while in care, it was alleged that the facility did not provide hydration to R1 resulting to dehydration. Investigator Douglas medical review on 10/12/22 revealed that R1 was admitted at the hospital on 09/19/22 and was diagnosed with dehydration resulting from other medical condition. Investigator Douglas’ interview with staff on 10/14/22, however, revealed that the staff provided five (5) bottles of water every day. Investigator Douglas’ phone interview with R1’s partner on 10/06/22 however, revealed that R1’s partner regularly visited R1 at the facility and stayed an average of four (4) to five (5) hours almost every day, observed that the facility staff did not provide any kind of hydration while R1’s partner was at the facility.

Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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:
11/01/2023
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Yelena Aladadyan - AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegations. LPA met with the Administrator Yelena Aladadyan and explained the reason for today’s visit.

During the initial visit on 09/22/22 at 9:50 AM, LPA Martinez obtained copies of facility documents relevant to the investigation. This complaint was referred to the Investigation Bureau (IB) on 09/20/22 and was assigned to IB Investigator Dennis Douglas.

Regarding the allegation that Resident sustained multiple pressure injuries while in care, it was alleged that Resident #1 (R1) had multiple wounds that were caused by not being moved as R1 was bed bound.

(continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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: 11/01/2023
NARRATIVE
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(continued from LIC 9099)

Investigator Douglas’ record review revealed that R1 was admitted at the facility on 07/01/22 and was admitted for hospice services on 07/02/22 and had an initial wound assessment by a Wound Care nurse of a separate Wound Care company on 07/07/22 but R1 had no pressure injury at this time, only wounds on the upper mid torso. Further review also revealed that only on 07/28/22 visit by the Wound Care nurse that R1 was assessed with new pressure wounds on lower back, coccyx and bilateral buttocks while under the care and continuous visit of the Wound Care company. Moreover, records also showed that aside from the regular visit of Hospice nurse twice a week, the Wound Care nurse had also regularly visited R1 about twice to three (3) times a month. Investigator Douglas’ interview with staff on 10/14/22 revealed that staff turns R1 every hour per instruction of the Hospice nurse.

Based on the information gathered during the course of the investigation, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2023
Section Cited
HSC
1569.312(e)
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Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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Administrator agreed to submit a Statement of Understanding and step by step plan to avoid similar issues from happening again regarding meeting basic care needs of the residents and will submit to CCL on or before the POC date.
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This requirement is not met as evidenced by:

Based on IB's interview, the licensee did not ensure that R1 was hydrated while at the facility which poses an immediate health and safety risk to the 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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6