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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610300
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:19:01 PM

Substantiated


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
09/27/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20240927090148
FACILITY NAME:QUEST BEHAVIORAL HEALTH INCFACILITY NUMBER:
197610300
ADMINISTRATOR:MELIKYAN, ARMENFACILITY TYPE:
772
ADDRESS:43828 47TH STREET WESTTELEPHONE:
(661) 579-6666
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marine GuloyanTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff, with the client's participation, did not review the treatment/rehabilitation plan on an on-going basis.
Staff did not meet the minimum qualifications to provide direct service to client(s).
INVESTIGATION FINDINGS:
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On 10/01/2024 at 9:45 a.m., LPA Evelin Rios arrived at the facility mentioned above to conduct an unannounced complaint investigation. LPA was greeted by staff #1 (S1) and granted access. S1 contacted the Program Director, Marine Guloyan and the Executive Director, Armen Melikyan by telephone to inform them LPA was at the facility. At 10:18 a.m. LPA met with Marine Guloyan and spoke with Armen Melikyan via telephone. LPA explained the reason for the visit. An entrance interview was conducted.

At 9:50 a.m. LPA along with S1 conducted a tour of the facility to assure the health and safety of the clients in care. There were no issues or concerns found.

Allegation #1: Staff, with the client's participation, did not review the treatment/rehabilitation plan on an on-going basis.
(Continued to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 3
Control Number 31-AS-20240927090148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUEST BEHAVIORAL HEALTH INC
FACILITY NUMBER: 197610300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
81068.3(d)
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(d) The program director or staff person... shall, with the client's participation, review the treatment/rehabilitation plan according to the schedule set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Section 532.2(c). This requirement is not met as evidenced by:
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LPA reviewed current client progress in treatment and observed comments completed by the staff and signatures by the client. POC cleared on todays visit.
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Based on LPA's interviews and record review, the licensee failed to document ongoing reviews by staff and clients' of the treatment/ rehabilitation plan, which posed a potential health, safety and personal rights risk to residents in care.
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Type B
10/18/2024
Section Cited
CCR
81065(n)
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(n) All direct care staff shall meet the minimum qualifications as set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Sections 532.6(h) and (i).
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Licensee will provide the Plan of Correction requested by DHCS to LPA by POC due date 10/18/2024.
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Based on LPA's interviews and record review, the licensee failed to document a specific plan of supervision an in-service training which will guarantee the ongoing qualification of the employee to perform the job, which posed a potential health, safety and personal rights 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20240927090148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: QUEST BEHAVIORAL HEALTH INC
FACILITY NUMBER: 197610300
VISIT DATE: 10/01/2024
NARRATIVE
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 Regarding the allegation it was reported treatment/ rehabilitation plans reviewed for three (3) client records did not contain documented evidence of ongoing review of progress towards reaching established goals. To investigate the allegation LPA conducted an interview with Marine and Armen. At 10:18 a.m. LPA reviewed electronic records of one (1) out of five (5) current client written treatment/rehabilitation plans specifying goals and objectives. According to Marine at the time when Department of Health Care Services (DHCS) conducted their visit, the then clients progress was only documented in the progress notes viewable to the the therapist only. Client signature were obtained when they would meet with the therapist to discuss their progress. According to Marine, the Department of Health Care Services wanted to see documentation of clients progress in the comment section of the records they use when they meet with clients. LPA observed the comment section is viewable by the client giving them access to view what progress or lack of progress they are making towards their goals. Five (5) out of five (5) current client records have ongoing notes documented in the comment section of their treatment/rehabilitation plans. Based on interviews and review of the summary report by DHCS the allegation is substantiated at this time.

Allegation #2: Staff did not meet the minimum qualifications to provide direct service to client(s). Regarding the allegation it was reported that four (4) personnel records did not contain documented evidence that the employees had one (1) year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities or a documented plan of supervision. To investigate the allegation LPA conducted an interview with Marine and Armen. LPA reviewed training documentation for one (1) staff and found staff training to be ongoing and documented with the topic covered and staff signature. However, the record did not have on file a specific plan of supervision and in-service training for the employee which will guarantee the ongoing qualification of the employee to perform the job. The plan should include but not be limited to the frequency and number of hours of training, the subjects to be covered, and a description of the supervision to be provided. According to Armen, the staff training meets the in-service training for the employee for ongoing qualifications. Although there is documentation of completed training there is no documentation of the specific plan of supervision. According to Marine, DHCS would want them to meet with staff one on one on an ongoing basis to discuss progress towards qualification. Based on interviews and review of the summary report by DHCS the allegation is substantiated at this time.

Deficiency's cited (refer to LIC9099-D). Appeals provided. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3