198320378-12-20-2023-11-AS-MVAO-D3CT9S-20240314143226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 12/20/2023
Date Signed: 12/20/2023 05:01:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
12/14/2023 and conducted by Evaluator David Espana

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231214094855

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: 43	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Narine Mertkhanyan		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff yell at resident(s) in care.
Staff speak inappropriately to resident(s) in care.
Staff member smokes marijuana on facility premises.
Facility does not have an Administrator.

INVESTIGATION FINDINGS:

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On 12/20/2023 at 09:00 am Licensing Program Analyst (LPA) David España conducted an initiated a 10-day complaint investigation visit for the allegation listed above. Upon arriving at the facility, LPA met with S#1 and later S#2 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is not clear of Covid-19 infection (Has one case). LPA was granted access and allowed to enter the facility to conduct inspections. During the records review, LPA observed and requested copies of the annual staff training for residents' personal rights. Also, LPA observed the rights posted on the facility walls. In addition, LPA observed and requested copies of the personal rights in the resident's admissions agreement; with signatures of representatives upon moving into the facility. LPA requested copies of the following: Staff and Resident Roster, staff ratios, Physician report, Needs and Service, incident reports of residents (see LIC-811s). Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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 4

Control Number 11-AS-20231214094855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 12/20/2023

NARRATIVE

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On 12/20/2023 Licensing Program Analyst (LPA) David España conducted interviews with Eight (8) out of Twelve (12) current staff members working at the time of visit with a total of Twenty-One (21) staff member employed. At 10:30 am LPA confirmed that there are Forty-Three (43) residents in care at the time of visit. LPA confirmed there are Twenty-One (21) total staff employed as of 12/20/2023. LPA confirmed there is only Four (4) resident in care who receive oxygen as of 12/20/2023. LPA confirmed there are only One (1) total resident in care with dementia at the time of visit 12/20/2023. LPA confirmed there are Six (6) total residents in care with wheelchairs at the time of visit 12/20/2023. LPA confirmed there are Ten (10) total residents in care with diapers at the time of visit 12/20/2023.
Investigation Revealed the Following:

Allegation: Staff yell at resident(s) in care.

The details of the complaint alleged that a staff member yelled at a resident in care. During the records review, LPA reviewed staff yearly training regarding residents' personal rights. All staff have taken the training. During an interview with the Administrator (A#1) and Seven (7) out of Twelve (12) staff members, per A#1 stated that all staff know the residents' rights and do annual training. In addition, per (A#1), she said no staff has yelled at a resident before. (A#1) said, "We do not scream or yell at our residents; we only speak loudly to them when they have a hard time hearing us." During interviews with Four (4) out of Forty-Three (43) residents stated that they personally have not had issue with a staff member at the facility, and no staff has ever yelled or screamed at them. During interviews with Eight (8) out of Twelve (12) current staff members stated that they are familiar with the resident's rights, and Eight (8) out of Twelve (12) current staff members stated that they have never yelled or screamed at a resident.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff yell at resident(s) in care.”

Investigation Revealed the Following:

Allegation: Staff speak inappropriately to resident(s) in care.

The details of the complaint alleged that a Staff speaks inappropriately to resident(s) in care. LPA interviewed Administrator Narine Mertkhanyan who stated she has not received any reports of staff speaking to a resident inappropriately. LPA interviewed with Four (4) out of Forty-Three (43) residents regarding the allegation.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231214094855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 12/20/2023

NARRATIVE

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Of those interviewed, Four (4) out of Forty-Three (43) residents stated staff do not speak inappropriately to them with one not being able to answer due to their diagnosis. Eight (8) out of Twelve (12) staff interviewed, Eight (8) out of Twelve (12) staff stated there has not been any issues with staff speaking inappropriately to resident. LPA also interviewed Four (4) out of Forty-Three (43) residents stated there were no issues with staff speaking inappropriately to resident.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff speak inappropriately to resident(s) in care.

Investigation Revealed the Following:

Allegation: Staff member smokes marijuana on facility premises.

Based on the interviews conducted with Four (4) out of Forty-Three (43) residents, statements obtained did not corroborate this allegation. Eight (8) out of Twelve (12) staff interviewed statements obtained did not corroborate this allegation. The details of this allegations state that staff smoke marijuana on the premises - when staff works in a rooms where staff closes door and smokes marijuana in a room. LPA toured the facility with staff, namely rooms #15, #17, #77, #71, #34, and #19. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents, statements obtained did not corroborate this allegation. Eight (8) out of Twelve (12) staff interviewed have not observed Marijuana smoke coming out of rooms or facility. Based on the information gathered, there is not sufficient evidence to support this allegation " Staff member smokes marijuana on facility premises.”

Investigation Revealed the Following:

Allegation: Facility does not have an Administrator.

Based on the interviews conducted with Four (4) out of Forty-Three (43) residents, statements obtained did not corroborate this allegation. Based on the interviews conducted with Eight (8) out of Twelve (12) staff interviewed statements obtained did not corroborate this allegation. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents they have met with certified Administrator. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents stated that the Administrator should devote more time.

Continued on LIC9099-C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20231214094855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 12/20/2023

NARRATIVE

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Based on the interviews conducted with Four (4) out of Forty-Three (43) residents stated that the Administrator manages two facility at this time of visit. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents felt that there should be sufficient number of hours to permit adequate attention to residents. Based on the interviews conducted with Eight (8) out of Twelve (12) staff stated the Administrator does provide adequate time and personal integrity to the facility. Eight (8) out of Twelve (12) staff stated that they are provided guidance from the Administrator for the standard care and supervision of Forty-Three (43) residents in care.

Based on information gathered, LPA did not find sufficient evidence to support allegation "Facility does not have an Administrator.”

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Administrator Narine Mertkhanyan and a hard copy was provided the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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