198603213-8-30-2022-28-AS-MVAO-CJHTUC-20220922150208

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603213
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:14:05 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
07/14/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220714121005

FACILITY NAME:	COMFORT CARE ASSISTED LIVING FACILITY		FACILITY NUMBER:	198603213
ADMINISTRATOR:	AVETIKYAN, OLGA		FACILITY TYPE:	740
ADDRESS:	731 MILFORD STREET		TELEPHONE:	(747) 283-6125
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY:	6	CENSUS: 5	DATE:	08/30/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Susanna Avetian, Staff		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to deliver findings for the allegation listed above. LPA met with Staff and explained the purpose of the visit. LPA spoke to Administrator, Viktorya Hayrapetyan, via telephone and read the report.

The investigation consisted of the following:
On 7/15/22, LPA Chan conducted the initial visit and toured the facility. LPA did not observe any health and safety concerns. There was at least 2 days of perishable and a week of non-perishable food supply. LPA obtained copies of the staff roster, resident roster, and documentation pertaining to Resident #1. Interviews were conducted with the Administrator and staff.

The investigation revealed the following:
Allegation - Resident sustained multiple pressure injuries while in care. It was alleged that Resident #1 (R-1) was brought to the hospital with pressure ulcers in the lower extremity and sacrum area with some being

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: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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-20220714121005

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: COMFORT CARE ASSISTED LIVING FACILITY	FACILITY NUMBER: 198603213
	VISIT DATE: 08/30/2022

NARRATIVE

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unstageable. According to the Administrator, Resident #1 (R-1) was admitted to the facility on 6/18/22 from the Adventist Hospital. R-1 already had pressure injuries prior to admission and Administrator ensure that resident was admitted to hospice in order to retain resident. LPA reviewed the hospice agency report and verified with the hospice registered nurse that R-1 was admitted on 6/18/22 with pressure injuries on both hips, back, and legs. R-1's hospital records with discharge date of 6/18/22 indicated "decubitus ulcer with suspected deep tissue injury, unstageable". R-1's appraisal form also indicated that resident had multiple large decubitus ulcers in the sacral areas, bilateral hips, left lower extremity and right foot. There was an additional form in which the resident's daughter acknowledged and signed regarding the pressure ulcers observed upon admission. Photos of the pressure wounds were obtained. Staff also verified that resident was admitted with the pressure wounds noted.

Per the Administrator, R-1 was hospitalized from 6/29/22 - 7/5/22. She stated that the resident returned with additional wounds on the back side and heels. LPA interviewed R-1's wound specialist who confirmed treating the multiple wounds that were present during admission and also verified the additional wounds observed on the day that resident returned from the hospital. Based on the information gathered, the resident was enrolled to the facility with pressure wounds and did not obtain any new wounds while at the facility.

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 conducted with Staff. 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: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

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