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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610318
Report Date: 03/29/2024
Date Signed: 03/29/2024 12:21:06 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
03/20/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240320145409
FACILITY NAME:EMERALD SENIOR CARE,INC.FACILITY NUMBER:
197610318
ADMINISTRATOR:HAYRAPETYAN, ELENFACILITY TYPE:
740
ADDRESS:10401 ENCINO AVE.TELEPHONE:
(747) 300-2232
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Hayk Margaryan - AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not allowing resident to leave the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with

LPA conducted physical plant tour at 9:15 AM, requested copies of facility documents relevant to the investigation at 9:33 AM and interviewed residents and staff between 10:30 AM to 11:40 AM. It was alleged that Resident #1 (R1) was not allowed to leave the facility with R1's Power of Attorney (POA) by the facility staff. LPA's record review today at 10:00 AM revealed that R1 was admitted at this facility on 05/23/23 and had revoked R1's POA on 01/27/2024. Further review also revealed that R1 was able to follow instruction and able to communicate own needs and does not have dementia diagnosis. LPA's interview with R1 revealed that R1 was aware that R1 revoked own POA and did not want to leave the facility. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
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: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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