197610567-7-23-2024-31-AS-TAGD-D8HLHD-20240826084606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610567
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:01:42 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
07/11/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240711170640

FACILITY NAME:	SAINT MARIAM SENIOR CARE		FACILITY NUMBER:	197610567
ADMINISTRATOR:	HAYRAPETYAN,VIKTORYA		FACILITY TYPE:	740
ADDRESS:	18228 ACRE STREET		TELEPHONE:	(213) 476-2354
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Viktorya Hayrapetyan		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff pushed a resident in care
Staff yells at the residents in care

INVESTIGATION FINDINGS:

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On 07/23/24, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administator, Viktorya Hayrapetyan. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 07/16/2024, Licensing Program Analyst (LPA) Gina Saucedo initiated the complaint investigation. On 07/23/24, LPA Saucedo asked for the census, staff, and resident files. On 07/23/24, LPA Saucedo interviewed additional staff conducted a physical tour, gathered additional information, and delivered findings.

9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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 5

Control Number 31-AS-20240711170640

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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
	VISIT DATE: 07/23/2024

NARRATIVE

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Regarding the allegation: Staff pushed a resident in care. It is being alleged that one (1) of the residents suspects that a nurse pushed their wheelchair from behind as they were going down the ramp that goes outside, causing them to put their hand out to catch themselves. LPA interviewed four (4) out of six (6) residents that confirmed that they have never been pushed while in care. Resident #1 (R1) was able to confirm that they had fallen on their own. Three (3) out of three (3) staff confirmed that R1 did fall while going down the ramp. Staff also reported that R1 does not like to wait for staff for help. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff yells at the residents in care. It is being alleged that there are staff at the facility that yell at residents. Although, resident #1 (R1) did confirm that the staff are loud, they did not confirm that staff yell at them. LPA interviewed four (4) out of six (6) residents of which three (3) residents confirmed that staff do not yell at them. Three (3) out of three (3) staff confirmed that they do not yell at residents. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
07/11/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240711170640

FACILITY NAME:	SAINT MARIAM SENIOR CARE		FACILITY NUMBER:	197610567
ADMINISTRATOR:	HAYRAPETYAN,VIKTORYA		FACILITY TYPE:	740
ADDRESS:	18228 ACRE STREET		TELEPHONE:	(213) 476-2354
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Viktorya Hayrapetyan		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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9

Staff did not provide assistance to a resident in care

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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 5

Control Number 31-AS-20240711170640

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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
	VISIT DATE: 07/23/2024

NARRATIVE

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Regarding the allegation: Staff did not provide assistance to a resident in care. It is being alleged that resident #1 (R1) fell on the floor and was left there overnight. Three (3) out of three (3) staff did confirm that R1 continues to fall because they need assistance. Three (3) out of three (3) staff did state R1 needs a minimum of two (2) people to move them around. LPA interviewed four (4) out of six (6) residents that confirmed that they do need assistance and have no way of getting assistance when needed. LPA observed that six (6) out of six (6) residents do require specific assistance according to their file review which is not being met according to their individual needs. Therefore, based on the LPA's observations, record review, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time.

An exit interview was conducted, a citation(s) was issued for the above allegation(s), Appeal rights and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20240711170640

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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/24/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities:(a) ...Personal Rights of Residents... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4)To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Adminstrator is to provide training to all staff to identify individual needs of residents. POC 07/24/24
	8 9 10 11 12 13 14	Based on the LPA observation and interviews the licensee/administrator did not provide assistance to a resident in care regarding their individual needs which poses an Immediate Health, Safety or Personal Rights risks to persons 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: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5