198320378-2-29-2024-11-AS-UCOL-D2XW38-20240301155532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 12/04/2023
Date Signed: 02/29/2024 11:23:33 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231128163348

FACILITY NAME:	HOLIDAY VILLA		FACILITY NUMBER:	198320378
ADMINISTRATOR:	ZENOU, ADAM		FACILITY TYPE:	740
ADDRESS:	1447 17TH STREET		TELEPHONE:	(310) 829-5904
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	174	CENSUS: 44	DATE:	12/04/2023
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Narine Mertkhanyan, Administrator		TIME COMPLETED:	04:44 PM

ALLEGATION(S):

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Staff did not respond in writing regarding any action or inaction taken in response to resident council concerns or recommendations within 14 calendar days.

INVESTIGATION FINDINGS:

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On 02/29/24 Licensing Program Manager, Ulysses Coronel (LPM), and Licensing Program Analyst (LPA), Mario Leon, arrived at the facility to deliver an amended document. This is an ammendment of the complaint investigation report delivered on 12/04/23. The purpose of this amendment is to provide additional information. LPM and LPA were met by Anne Marie Chan, Business Office Manager and there have been no changes to the initial findings.
On 12/04/23 LPA requested facility documents and toured the facility. LPA interviewed four (4) out of forty-four (44) residents and three (3) out of nineteen (19) staff.
The investigation consisted of the following:

12/04/23 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unanounced, complaint visit at the above-mentioned facility. LPA was met by Ashley Trimble, Activities Director, and later by Narine Metkhanyan, Administrator (S1).
Report continues see LIC9099C

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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 11-AS-20231128163348

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 12/04/2023

NARRATIVE

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The investigation revealed the following:
Regarding the allegation: "Staff did not respond in writing regarding any action or inaction taken in response to resident council concerns or recommendations within 14 calendar days.". It has been alleged that Administrator, Narine Mertkhanyan (S1) had not responded to the resident council's request on 10/31/23. LPA interviewed three (3) staff (S1-S3). One (1) staff has denied the allegation, one (1) staff agrees with the allegation and one (1) staff was unaware of the allegation. LPA interviewed four residents (R1-R4). All residents have agreed with the allegation.
Record reviews revealed that the email sent to the above-mentioned facility, from resident council at 11:20AM on 10/31/23, did not contain any response from facility staff members. The same email, presented to LPA from the facility, did not present any element of response, in writing, made to the resident council.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099D.

An exit interview was conducted on 12/04/23 with Narine Mertkhanyan, Administrator, and a copy of facilities’ appeal rights and this report has been provided to Anne Marie Chan, on 02/29/24, Business Office Manager.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231128163348

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HOLIDAY VILLA	FACILITY NUMBER: 198320378
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/14/2023 Section Cited CCR 87468.2(a)(24)(c)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,....shall have all of the following personal rights: (24) To organize and participate in a resident council...HSC1569.157.	1 2 3 4 5 6 7	LPA and Administrator have agreed that, moving forward, facility will respond in writing to residents' concerns or recommendations. Town-hall meetings will address the concerns and recommendations presented by residents.
	8 9 10 11 12 13 14	(c)If a resident council submits written concerns..respond in writing..within 14 calendar days. This has not been met as evidenced by: LPA observed email written to Administrator(S1) on 10/31/23. S1 forwarded email to fellow staff, not respond to resident(s) in writing	8 9 10 11 12 13 14	Each monthly flyer will display topic(s) to be discussed, including residents' concerns and recommendations. Monthly flyer(s) will be sent to Mario.Leon@DSS.CA.GOV.
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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.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

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