198603493-3-20-2024-28-AS-TVAO-D4LT7R-20240423142909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603493
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:03:40 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
03/14/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240314100258

FACILITY NAME:	MOON LIGHT BOARDING CARE INC		FACILITY NUMBER:	198603493
ADMINISTRATOR:	SAKO MANVELYAN		FACILITY TYPE:	740
ADDRESS:	120 N SIERRA BONITA AVE		TELEPHONE:	(818) 661-7333
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	6	CENSUS: 3	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	11:32 AM
MET WITH:	Sako Manvelyan - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not meet resident's oxygen needs
Staff do not treat resident with dignity

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 Sako Manvelyan and explained the reason for the visit.

The investigation consisted of the following: LPA requested staff/resident roster. Interviewed 3 residents and 2 staff, reviewed Resident’s #1(R1) file and requested copies of physician’s report, preplacement appraisal information, admission agreement, needs and care plan, and medication sheet and staff’s personal rights training.

The investigation revealed the following: Regarding allegation: Staff do not meet resident's oxygen needs. It is alleged staff is denying R1's oxygen. Interviews with three residents revealed facility staff provide assistance as needed for as needed medication when residents have asked including oxygen.

(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: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20240314100258

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: 03/20/2024

NARRATIVE

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However, one resident stated oxygen is provided but staff have stated they do not know how to place it in R1’s nose properly when providing it. Interviews with staff revealed staff assist R1 when oxygen is requested as needed and have not denied oxygen to R1. Interviews with R1’s family member revealed R1 is able to place oxygen properly as long as it is past to R1 and do not have concerns about facility providing oxygen.

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: Staff do not treat resident with dignity. It is alleged staff tells resident is being dramatic and does not assist resident. Interviews with residents revealed 2 out of 3 residents stated staff treat them and speak to them respectfully. 1 out of 3 residents stated that staff seem to be unhappy when providing care and facility staff do assist but have resident wait for care. LPA inquired on wait time for assistance, resident replied is about 5 minutes. Interviews with staff revealed staff respond to residents’ request as soon as possible. The only time they asked residents to wait is when they are assisting other residents. At which time they probably have the resident wait about 5 minutes before providing assistance. Facility staff stated to be respectful to residents. Facility staff received training on resident’s personal rights on April 12, 2023.

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 Sako Manvelyan 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: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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