198603270-6-21-2022-28-AS-SCOL-CFSN2S-20220627100510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603270
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:52:24 AM

Unfounded

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
06/16/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220616110139

FACILITY NAME:	GRANT SERENITY HOMES OF PASADENA, INC.		FACILITY NUMBER:	198603270
ADMINISTRATOR:	GEVORKIAN, NVARD		FACILITY TYPE:	740
ADDRESS:	1745 WAGNER STREET		TELEPHONE:	(818) 425-6797
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	6	CENSUS: 6	DATE:	06/21/2022
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Nvard Gevorkian - Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility not allowing residents to choose Hospice service of resident's choice.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met Lida Gasparyan Caregiver with and explained the reason for the visit. Nvard Gevorkian arrived 15 minutes later.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster, interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),LPA was unable to interview resident #6(R6), and administrator. LPA reviewed 6 residents files and requested copies of identification and emergency information sheet, physician's report, admission agreement, personal rights addendum for R1,R2,R3,R4,R5,R6 and hospice documents for R2,R3,R5.

The investigation revealed the following: Regarding allegation: Facility not allowing residents to choose Hospice service of resident's choice. It is alleged a resident was admitted into the facility and on the same day the administrator told the family that they can only be on their own hospice services.
(CONTINUED ON LIC 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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-20220616110139

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: GRANT SERENITY HOMES OF PASADENA, INC.	FACILITY NUMBER: 198603270
	VISIT DATE: 06/21/2022

NARRATIVE

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Interviews with residents revealed 2 out of 5 residents stated that they feel they would be allowed to make their choice of hospice agency. 3 out of 5 residents interview were unable to communicate due to cognitive skills. LPA was unable to interview 1 resident due to isolation requirements. Interview with administrator revealed alleged resident does not reside at the facility and resident's are given the choice to choose their hospice agency. Administrator does not request families to change hospice agency upon admission or during care of residents. Administrator has stated to not own a hospice agency or to be affiliated with a hospice agency for financial gain. Documents reviewed revealed alleged resident is not listed in resident's roster. Resident's file reviewed R1 and R3 were admitted to the facility on 6/2/22 and do not match the name for the alleged resident. 3 out of 6 residents residing at the facility are currently under hospice care agencies. The 3 residents are receiving services from 2 different hospice agencies, R3 receives services from St. Vincent Hospice Services Inc. and R2 adn R5 receive services from Compassionate Hospice Care, Inc. Based on documents reviewed LPA Flores determined that there was insufficient evidence to support the above stated allegations.

This agency has investigated the complaint alleging, Facility not allowing residents to choose Hospice service of resident's choice. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without reasonable basis. We have therefore dismissed the complaint.

Exit interview was conducted with Nvard Gevorkian Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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