198601054-4-19-2022-28-AS-SCOL-CFSU63-20220627151739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601054
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:16:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220401135020

FACILITY NAME:	PARKVIEW MANOR		FACILITY NUMBER:	198601054
ADMINISTRATOR:	CHERTOK, VLADAMIR		FACILITY TYPE:	735
ADDRESS:	5055 NOVGOROD STREET		TELEPHONE:	(323) 225-4293
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90032
CAPACITY:	86	CENSUS: 77	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Elena Novikova, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Questionable death of clients.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegation listed above. LPA arrived unannounced and met with Administrator, Elena Novikova. The reason for the visit was explained.

On 4/4/22, LPA Chan conducted the initial investigation to check on the health and safety of the clients. LPA toured the facility and obtained copies of the staff roster, client roster, and weekly food menus. LPA randomly selected 8 rooms to inspect. LPA also inspected the food supplies and observed sufficient 2-day perishable and a week of nonperishable items. LPA interviewed the Administrator, 4 Staff and 9 Clients. Documents pertaining to the known death of a client were also obtained.

Regarding allegation - Questionable death of clients. It was alleged that two clients died of malnutrition within a year. For this investigation, LPA interviewed the Administrator, Staff, and Clients.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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 28-AS-20220401135020

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PARKVIEW MANOR	FACILITY NUMBER: 198601054
	VISIT DATE: 04/19/2022

NARRATIVE

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According to the interviews with Staff and Clients, they acknowledged only one client (Client #1) who passed away at the facility in 2021. Staff stated that Client #1 was found unresponsive in the morning. They do not believe the client was malnourished as Staff indicated that Client ate every day and was medication compliant. Clients who knew or heard about Client #1's death did not feel that the cause was due to a lack of neglect from staff or malnutrition. The clients interviewed stated that they were fed daily and provided with adequate servings. LPA obtained a copy of Client #1's death certificate which stated Client passed away on 3/13/21 and the cause of death was hypertensive heart disease.
Based on interviews and record review, there is no supporting evidence that client passed away due to malnutrition.

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

An exit interview was held. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

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