197610441-5-6-2024-31-AS-NGID-D5AP3U-20240515105807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610441
Report Date: 05/06/2024
Date Signed: 05/06/2024 03:41:18 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
04/18/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20240418101816

FACILITY NAME:	A NEW LIFE BOARD AND CARE		FACILITY NUMBER:	197610441
ADMINISTRATOR:	KARAPETYAN, GURGEN		FACILITY TYPE:	740
ADDRESS:	19435 STRATHERN ST		TELEPHONE:	(747) 237-2337
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 5	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	Gurgen Karapetyan, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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At 12:15 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit. LPA met with Gurgen Karapetyan, Administrator and disclosed the reason for the visit.

An initial visit was conducted on 04/26/24. At 09:45 AM, LPAs requested resident and staff roster. At 10:00 AM, LPAs requested copies of pertinent information which include, but not limited to Centrally Stored Medication and Destruction Record (CSMDR), Physician’s Report, Hospital Discharge Papers, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:10 AM, the team conducted a physical plant tour. Between 10:30 AM – 12:45 PM, the team conducted an interview with the Administrator, three (3) Staff, and three (3) out of five (5) residents who were able to communicate, and a family member of a resident.
Continue on LIC 9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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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Control Number 31-AS-20240418101816

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A NEW LIFE BOARD AND CARE	FACILITY NUMBER: 197610441
	VISIT DATE: 05/06/2024

NARRATIVE

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Illegal Eviction:
It was alleged that the facility refused to take Resident #1 (R1) back after hospital discharge on 04/19/2024. During initial visit, LPAs were informed that the level of care for R1 changed; and therefore, the facility could not accept R1 back to the facility. However, upon LPA’s request, the Administrator could not provide sufficient document regarding R1’s changes in the level of care. Additionally, the investigation revealed the Administrator did not submit the Eviction letter to the Community Care Department nor served R1/family/representative with the 30-day Eviction notice. Based on interviews and record reviews this allegation is Substantiated at this time.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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.RO, 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
04/18/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20240418101816

FACILITY NAME:	A NEW LIFE BOARD AND CARE		FACILITY NUMBER:	197610441
ADMINISTRATOR:	KARAPETYAN, GURGEN		FACILITY TYPE:	740
ADDRESS:	19435 STRATHERN ST		TELEPHONE:	(747) 237-2337
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 5	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	Gurgen Karapetyan, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not assist resident in a timely manner
Facility is in disrepair
Staff did not order resident's medication refills in a timely manner
Staff engaged in a verbal altercation in the presence of residents
Staff did not provide a safe and comfortable environment for residents

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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-20240418101816

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A NEW LIFE BOARD AND CARE	FACILITY NUMBER: 197610441
	VISIT DATE: 05/06/2024

NARRATIVE

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Staff did not assist resident in a timely manner:
In regards to the allegation, it was reported that on or around 04/17/2024, R1 required an assistance and was unable to press the call button due to the device being too far. To investigate this allegation, during initial visit, LPAs conducted an interview with the Administrator and were informed that the staff always makes sure to have emergency call buttons close to the residents’ bed, so they can call for an assistance. Interview with two (2) staff members revealed that as soon as the resident calls for help they respond immediately or within 10 minutes. In addition, both staff members informed LPAs that on 04/17/24, when R1 called for help the staff responded within five (5) to seven (7) minutes because both caregivers were busy helping other residents. Lastly, three (3) of the five (5) residents confirmed that the staff always provided assistance in a timely manner, and expressed no concern regarding the above allegation. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not assisting a resident in a timely manner, or staff not meeting a resident's diapering need. Therefore, the allegations are deemed Unsubstantiated at this time.

Facility is in disrepair:
It was alleged the facility’s alarm, bulb (light), and blinds are not in good repair. During the initial visit on 04/26/2024, the team was able to do a facility tour. The team did not observe any broken alarm, bulb (light), and blinds during the visit. LPAs inspected all alarms, lights, and blinds of the facility and found all of them in good repair and functional. Interviews with three (3) out of five (5) residents revealed that they had no issues with the alarm, lights, and broken blinds. Based on the inspection and observation, this allegation is Unsubstantiated.

Staff did not order resident's medication refills in a timely manner:
In regard to the above allegation: Staff failed to refill residents’ medication on a timely manner, LPA conducted an interview with R1’s family and was informed that R1’s medication for diabetes ran out and the facility failed to notify the family to refill and deliver a new bottle. In addition, during the initial visit, LPA conducted review of R1’s Centrally Stored Medications and Distraction Records (CSMDR) and observed that the bottle quantity was 200 tablets and prescribed to be taken twice a day. The start date of the medication was 01/26/2024. On 04/17/2024 the bottle had 34 pills left which was another sixteen (16) days’ supply. Lastly, all residents interviewed stated they had no issues receiving medication refills. Based on the record review and interviews conducted, there is insufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated. Continue on LIC 9099C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20240418101816

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A NEW LIFE BOARD AND CARE	FACILITY NUMBER: 197610441
	VISIT DATE: 05/06/2024

NARRATIVE

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Staff engaged in a verbal altercation in the presence of residents:
It was alleged that the Staff and the family member of R1 were engaged in a verbal altercation in the presences of other residents. To investigate this allegation, LPA conducted an interview with the Administrator and two (2) staff members and was informed that on 04/13/2024, there was a verbal communication not an altercation between staff and R1’s family member. Moreover, interview with R2’s family member and three (3) out of five (5) resident who were able to communicate, confirmed that the conversation between S1 and R1’s family member escalated to a verbal altercation. However, all parties also confirmed that S1 did not raise their voice and tried to de-escalate the situation. R1’s family member, on the other hand, behaved in a very unprofessional manner and created a big scene for no reason. In addition, all witnesses informed LPA that they felt sorry for S1 for not being able to respond back to R1’s family member. Thus, based on interviews and the information gathered, this allegation is deemed Unsubstantiated at this time.

Staff did not provide a safe and comfortable environment for residents:
Regarding the allegation Staff failed to provide a safe and comfortable environment for residents, it was alleged that the facility has a tenant on the second floor of the facility, and they have a vicious dog always present in the backyard of the facility. During the time of initial visit, the LPAs did not observe any vicious dog nor any kind of dog present at the facility. During today’s visit, LPA also did not observe nor heard any dog bark. LPA conducted an interview with the Administrator that the tenant at the second floor does have a dog. However, the dog is always kept upstairs in a locked room and does not ever go to the backyard unleashed. Interview with three (3) out of five (5) residents confirmed the information. Based on interviews and observation this allegation is unsubstantiated at this time.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20240418101816

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A NEW LIFE BOARD AND CARE	FACILITY NUMBER: 197610441
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2024 Section Cited CCR 87224(f)	1 2 3 4 5 6 7	87224(f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit a written statement about how eviction process will be conducted moving forward.
	8 9 10 11 12 13 14	Based on record review the licensee did not comply with the section cited above. LPA did not observe any proper documentation to evict R1.This poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

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