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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610495
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:56:00 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.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
07/30/2024 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20240730093716
FACILITY NAME:ROSSMOYNE HILLSFACILITY NUMBER:
197610495
ADMINISTRATOR:AVETISYAN, ARMINEFACILITY TYPE:
740
ADDRESS:1227 CAMPBELL STREETTELEPHONE:
(747) 324-6116
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY:6CENSUS: 4DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Albert KhachatryanTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility staff neglected resident
INVESTIGATION FINDINGS:
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At 9:30 a.m. on 08/06/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Staff #1 (S1) and disclosed the reason for the visit. LPA and Staff #2 (S2) toured the facility inside and out.

To investigate the allegation above, LPA interviewed the administrator at approximately 9:35 a.m. over the phone, S2 at approximately 10:10 a.m., Resident #1 (R1) at 10:30 a.m., and a visitor (V1) at 11:00 a.m., conducted a medication review at 10:20 a.m., toured the facility with S2 at 10:40 a.m., and conducted a records review of documents including but not limited to an admission agreement, preplacement appraisal, case notes, and medical assessment at 10:45 a.m.

Regarding the allegation “Facility staff neglected resident” it was alleged the facility did not provide sufficient care for R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20240730093716
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: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495
VISIT DATE: 08/06/2024
NARRATIVE
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Interview with the administrator revealed R1 was hospitalized on 07/26/24 due to excessive eating and drinking. R1 constantly requested food and water, and the facility provided them. R1 returned from the hospital on 08/04/24 with a catheter. The facility did not obtain any discharge paperwork from the hospital. Record review revealed R1 was diagnosed with bipolar disorder, schizoaffective disorder, hypertension, and diabetes type II. The preplacement appraisal noted R1 needed help with medication. R1’s needs and service plan was blank. No care plan to address R1’s care needs were observed. Interview with S2 revealed R1 ran out of all medications two (02) days ago and the facility has not provided medication assistance since then. Review of medications revealed R1’s bottle of Metformin was filled on 06/04/24 with sixty (60) doses and was empty. S2 stated the facility was instructed by V1 not to give R1 any more medications, so the facility did not assist with medications since R1 returned form the hospital. Based on interviews, medication review, and record review, the facility did not follow a care plan to address R1’s needs. The facility also did not sufficiently assist with R1’s medications. Therefore, the allegation is deemed SUBSTANTIATED at this time. This deficiency is cited on the corresponding LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20240730093716
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: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility ... shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal... and providing the other basic services
This requirement is not met as evidenced by:
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The licensee has agreed to provide a written statement regarding medication assistance for all residents.
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Based on interviews, record review, and observations, the licensee did not comply with the section cited above in one (01) out of four (04) residents by not providing sufficient assistance with medication, care, and supervision which poses a potential Health, Safety, or 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: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3