197610502-5-4-2026-31-AS-TAGD-DVBTG6-20260623144236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610502
Report Date: 05/04/2026
Date Signed: 05/04/2026 01:44:02 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.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
04/28/2026 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20260428125905

FACILITY NAME:	SAFEWAY SENIOR LIVING		FACILITY NUMBER:	197610502
ADMINISTRATOR:	SARGSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	15725 LEMARSH STREET		TELEPHONE:	(818) 344-5555
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	05/04/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Anna Sargsyan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not notify resident's DPOA of medication changes
Staff inappropriately placed resident on hospice without DPOA's consent

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Anna Sargsyan and explained the reason for the visit.

--- Staff did not notify resident's DPOA of medication changes

It was alleged that R1’s medications had been adjusted without the DPOA's knowledge. To investigate the allegation on May, 4 2026, LPA requested documents at around 9:30a.m. and interviewed one (1) staff from 10:30a.m. to 11:30a.m. A review of R1’s file revealed that the Responsible Party has Durable Power of Attorney for property only. LPA did not observe Medical Power of Attorney in the file. A review of the Medication Administration Records agrees with the Physician’s Orders. During interviews, staff stated they give all medications as prescribed by the physician.
(CONT on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

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-20260428125905

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: SAFEWAY SENIOR LIVING	FACILITY NUMBER: 197610502
	VISIT DATE: 05/04/2026

NARRATIVE

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Staff added they were in constant communication with the responsible party regarding R1’s care and received many letters of thanks and praise.

Based on interviews and record review, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff inappropriately placed resident on hospice without DPOA's consent

It was alleged that Responsible Party (RP) found out this week that facility had put Resident #1 (R1) on hospice twice without notifying them or giving a reason. To investigate the allegation on May, 4 2026, LPA requested documents at around 9:30a.m. and interviewed one (1) staff from 10:30a.m. to 11:30a.m. A review of R1’s Hospice Care and Palliative Care records revealed that they were both signed by R1’s DPOA. During interview, staff stated R1’s responsible party has always been notified and involved with everything regarding R1’s care. Staff added that both documents were signed by the DPOA.

Based on interviews and record review, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

LIC9099 (FAS) - (06/04)

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