197610264-8-27-2024-31-AS-EMIR-D9ANWB-20240920104914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610264
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:09:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/23/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230523152500

FACILITY NAME:	DREAM CARE FACILITY		FACILITY NUMBER:	197610264
ADMINISTRATOR:	GHOSALMYAN, GEVORG		FACILITY TYPE:	740
ADDRESS:	9849 CANEDO AVENUE		TELEPHONE:	(947) 777-0770
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 0	DATE:	08/27/2024
		UNANNOUNCED	TIME BEGAN:	01:27 PM
MET WITH:	Gevorg Ghosalmyan and Viktorya Hayrapetyan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Hospice Services obtained for resident contradictory to Hospice Waiver conditions.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Mariana Agban and Licensing Program Manager (LPM) Eva Miller conducted an announced subsequent investigative in office meeting for the purpose of this complaint. LPA and LPM met with the Licensee Gevorg Ghosalmyan and Administrator Viktorya Hayrapetyan.

Allegation: Hospice Services obtained for resident contradictory to Hospice Waiver conditions.

During today's meeting LPA obtained copies of facility documents relevant to the investigation including but not limited to R1's hospice documents, Physcian report, and Admission Agreement. LPA also conducted addtional interviews. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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 1