197610522-5-23-2024-31-AS-TAGD-D6SLEH-20240702084133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610522
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:00:00 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
05/17/2024 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240517163642

FACILITY NAME:	VELORI SENIOR LIVING		FACILITY NUMBER:	197610522
ADMINISTRATOR:	DANIELYAN, RENA		FACILITY TYPE:	740
ADDRESS:	20414 KESWICK STREET		TELEPHONE:	(818) 934-7783
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 6	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Irina Raskopina & Ivan Gorskikh		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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1. Facility is unkept
2. Staff changed resident's financial information without prior authorization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit to investigate the allegations mentioned above. LPA was greeted by caregiver Dilya Zhanisakova, who was informed the reason of the visit. Caregiver contacted Licensee Irina Raskopiana, who LPA spoke to over the phone and was also informed of the visit. Licensee arrived shortly after. The following was determined:

Allegation # 1: It is as alleged facility is unkept. During today’s visit, from 1030am to 3pm, LPA conducted interviews, a physical plant inspection and reviewed resident records. LPA observed all common areas, the living, dining, kitchen, resident rooms, and bathroom, to be clean and appropriately furnished for resident’s comfort. Therefore, based on observations, the allegation is Unsubstantiated.

Allegation # 2: It was alleged staff changed resident’s financial information without prior authorization. During today’s visit, from 1030am to 3pm, LPA conducted interviews, a physical plant inspection and reviewed resident records. LPA interviewed R1, who revealed to LPA, that R1 wanted copies of bank statements so

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240517163642

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: VELORI SENIOR LIVING	FACILITY NUMBER: 197610522
	VISIT DATE: 05/23/2024

NARRATIVE

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that R1 could withdraw money and get the balance of R1’s account. Staff did contact the power of attorney to inform R1’s request. Although the POA denied the request and staff did not take R1 to the bank. R1 walked to the bank and obtained copies of the bank statements and withdrew money without assistance. As R1 was returning to the facility, staff observed R1 walking and gave R1 a ride. Therefore, based on interviews, the allegation is Unsubstantiated at this time.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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