198603493-12-5-2023-28-AS-TVAO-CYBU6A-20231208141759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603493
Report Date: 12/05/2023
Date Signed: 12/05/2023 12:09:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/28/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231128133551

FACILITY NAME:	MOON LIGHT BOARDING CARE INC		FACILITY NUMBER:	198603493
ADMINISTRATOR:	NONA KHACHUNTS		FACILITY TYPE:	740
ADDRESS:	120 N SIERRA BONITA AVE		TELEPHONE:	(818) 661-7333
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	6	CENSUS: 2	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	Ruzanna Manukyan - Caregiver		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Facility staff slapped resident.
Facility staff yelled at resident(s).
Facility staff squeezed resident's arm resulting in bruising.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Ruzanna Manukyan Caregiver and explained the reason for the visit. Adrinne Adamanian Caregiver arrived 10 minutes later.

The investigation consisted of the following: LPA requested copies of staff/resident roster. LPA interviewed 2 residents and 3 staff. LPA requested copies of identification and emergency sheet for resident #3(R3). LPA attempted to interview R3’s representative over the phone.

The investigation revealed the following: Regarding allegations: Facility staff slapped resident and Facility staff yelled at residents. It is alleged staff was observed yelling at resident to "shut up" and by “slapping" resident on the shoulder. . Interviews with residents revealed, 2 out of 2 residents stated staff do not yell or hit the residents. Resident stated that staff are nice when providing care.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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-20231128133551

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOON LIGHT BOARDING CARE INC	FACILITY NUMBER: 198603493
	VISIT DATE: 12/05/2023

NARRATIVE

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Interviews with staff revealed staff do not yell or hit the residents while in care. Per administrator there is a camera in the common areas and upon review of footage that would have been notice. There have not been any incidents at the facility. LPA reviewed training provided to staff, last training received on elder abuse was conducted on 8/11/23.

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.

Regarding allegation: Facility staff squeezed resident's arm resulting in bruising. It is alleged staff was observed "squeezing" R3’s arm during the same incident, leaving a "black and blue" mark afterwards. Interview with residents revealed, 2 out of 2 residents stated staff have not left bruises in their bodies after assisting with care and staff “are really nice” when providing care. Interviews with staff revealed 3 out of 3 staff stated that staff provide care to residents in a respectful manner. LPA attempted to interview R3’s representative, however, was not able to obtain information regarding the allegations. LPA reviewed training provided to staff, last training on Promoting resident dignity, independence, individuality, privacy and choice was provided on 4/12/23.

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,

Exit interview was conducted with Adrine Adamian and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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