198320378-11-2-2023-11-AS-JHAD-D362GL-20240307162320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:18:56 PM

Unsubstantiated

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
10/25/2023 and conducted by Evaluator Jeremiah Randle

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231025152757

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: 41	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Narine Mertkhanyan Administrator.		TIME COMPLETED:	03:27 PM

ALLEGATION(S):

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Facility staff is not properly managing residents medication.
Staff did not ensure residents received prescribed medications.
Staff are not responding to residents call button in a timely manner.
Facility is falsely advertising services to prospective residents.

INVESTIGATION FINDINGS:

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The investigation consisted of the following:
LPA observed facility, as well as common areas of the facility. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair, LPA reviewed pertinent documents pertaining to the investigation. The following documents were gathered or reviewed: Staff and Client Rosters, file for resident (R1) and any other pertinent documentation needs and service, physician report, residency agreement, medication records for R1. On 11/01/2023 LPA Randle interviewed Narine Mertkhanyan Administrator (S1). On 11/01/2023 LPA interviewed residents (R1-R4). LPA requested, received, and reviewed the following information: file of R1, Staff roster, Resident roster, and other documents relevant to the investigation. LPA received the following pertinent documents pertaining to the investigation: Resident Roster, Staff Roster, Admissions Agreement, Needs and Services Plan, LPA reviewed Staff schedule, resident generated CALL ALERT signal times were not available due to system design, On 11/2/2023 LPA interviewed staff (S2-S5) and resident (R5). regarding the allegations listed above.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 11-AS-20231025152757

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: 11/02/2023

NARRATIVE

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Cont.

The investigation revealed the following:

Allegation: Facility staff is not properly managing residents’ medication.

LPA interviewed staff (S1-S5) and residents (R1-R5) regarding the allegation listed above. Staff S1and staff S2- S5 denied the allegation and confirmed use of central pharmacy were all resident using the facility for medication assistance and electronic recording MAR, LPA observed MARS of random resident and found no errors. Residents R2-R5 interviewed denied the allegation and all stated they did not have any issues with receiving medications on time or not having medication or receiving the wrong medication. R1 was interviewed regarding the allegation when R1 was asked if the facility was not properly managing his medication R1 stated to LPA “I handle my own medication, and I order my own medication the facility is not doing that for me I am independent”. During the course of the investigation, LPA was unable to find any documents or witnesses supporting the allegation above. LPA reviewed a copy of the R1’s admissions agreement, needs and services plan and physician report.

All staff S1-S5 and residents R2-R5 denied the allegation and stated there were no issues or concerns about the facility staff not properly managing residents’ medication.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20231025152757

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: 11/02/2023

NARRATIVE

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Cont.

Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff did not ensure residents received prescribed medications.

LPA interviewed staff (S1-S5) all denied the allegation. LPA interviewed residents (R1-R5) regarding the allegation listed above, residents R2-R5 denied the allegation. Staff S1 and Staff S2- S5 confirmed use of central pharmacy were all resident using the facility for medication assistance receives their medication. Residents R2-R5 interviewed denied the allegation and all stated they did not have any issues with receiving medications on time or not having medication per physician order. R1 was interviewed regarding the allegation when R1 was asked if the facility was not properly ordering R1’s medication, R1 stated to LPA “I handle my own medication, and I order my own medication the facility is not doing that for me I am independent”. During the course of the investigation, LPA was unable to find any documents or witnesses supporting the allegation above. LPA reviewed a copy of the R1’s admissions agreement, needs and services plan and physician report. LPA reviewed med cart for medication of random residents there were no cases were medication was not available for residents as prescribed.

All staff and residents R2-R5 denied the allegation and stated there were no issues or concerns about the facility staff not ensuring residents received prescribed medications..

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20231025152757

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: 11/02/2023

NARRATIVE

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Cont.

Allegation: Staff are not responding to residents’ call button in a timely manner.

LPA interviewed staff (S1-S5) and residents (R1-R5) regarding the allegation listed above. Staff S1- S5 confirmed residents use of centralized call system when residents have needs, or general announcement for activities meals, and or emergency notification. Staff S2-S5 interviewed denied the allegation and all staff stated, staff are responding to residents’ call button in a timely manner. Residents R2-R5 interviewed denied the allegation and all stated they did not have any issues with staff are not responding to residents’ call button in a timely manner. S1 stated to LPA “residents indeed activate there call buttons often for assistance for care and staff responds to the calls for assistance timely”. S1 stated to LPA that S1 was unaware of any complaints from R1 or any other resident regarding delayed assistance and denies the allegation. LPA interviewed resident R1. R1 stated to LPA “I used the call button twice” LPA asked if R1 recalled why R1 used the call button, R1 stated to LPA “I don’t remember when or why I used the button the first time, but the second time I think it was because someone knocked at my door”. LPA interviewed Staff S, S1 stated to LPA all the staff responds timely to every call for assistance from all the residents. LPA interviewed staff (S2-S5) and staff confirmed they respond quickly to the call alerts from residents promptly as trained. LPA interviewed residents (R2-R5). regarding allegations listed above -Staff did not answer resident's call button in a timely manner, residents R2-R5 interviewed by LPA reported they had not encountered a problem with staff not responding timely.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20231025152757

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: 11/02/2023

NARRATIVE

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Cont.

Allegation: The facility is falsely advertising services to prospective residents.

LPA interviewed S1, S1 denied the allegation. S1 stated all residents, or their responsible party are given a pamphlet of services and are required to sign admission agreement and care plans incorporated into their agreement and a provided a copy at the time of admission or shortly thereafter. LPA interviewed Business Office Manager S2, S2 denied the allegation. S2 confirmed all residents, or their responsible party are given a pamphlet of services and are required to sign admission agreement and care plans incorporated into their agreement and a provided a copy at the time of admission or shortly thereafter. S1 was asked by LPA if R1 made any request for services and if services advertised were denied S1 stated “no”. LPA asked Staff S2 if R1 made any request for services and if services advertised were denied S2 stated “no”. LPA reviewed resident R1’s file and required documents were in the file and signed. LPA interviewed R1, R1 was asked if he received a copy of his admissions agreement R1 stated to LPA ‘I think I have a copy of my paperwork’. R1 was asked how he heard about the facility R1 stated “ I think from a web site Caring dot com”. LPA asked R1 if R1 remembers seeing any advertising form this facility R1 stated “ I did not see any advertising about this place”. LPA interviewed resident (R2-R5) all denied the allegation, Resident R2- R5 confirmed that they have had no issues regarding false advertising or not receiving services..

Findings

Based on information gathered, the department did not find sufficient evidence to support the allegations listed above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to Narine Mertkhanyan Administrator (S1

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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