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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603605
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:48:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20241218135733
FACILITY NAME:ARARAT GARDENSFACILITY NUMBER:
198603605
ADMINISTRATOR:KESHISHYAN, VARSENIKFACILITY TYPE:
741
ADDRESS:1230 EAST WINDSOR ROADTELEPHONE:
(818) 244-7219
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:175CENSUS: 70DATE:
12/26/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Charles Brugh, Interim AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is not following approved fire clearance for non-ambulatory residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda, Angelica Segovia, and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced initial complaint visit to the facility and met with the Interim Administrator (Charles Burgh- S1).

It was alleged that non-ambulatory residents including resident #1 (R1) that are unable to ambulate without walker are residing on the second floor, which was not approved by The Fire Department.

To investigate the allegation, at 12:30 PM LPM and LPAs spoke with ED and Residents Care Director (RCD). At 2:15 PM LPAs requested and reviewed the staff and resident roster and copies of facility records pertinent to the investigation. Records included but not limited to randomly selected residents’ physician’s report, and admissions agreement(s).

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20241218135733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARARAT GARDENS
FACILITY NUMBER: 198603605
VISIT DATE: 12/26/2024
NARRATIVE
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Upon Review of residents’ records, LPM and LPAs observed that there were non-ambulatory residents, including R1 were residing on the upper levels (between 2nd and 4th floors) of the building that was not approved to retain non-ambulatory residents.

During this visit at 12:35 PM LPAs Ngo-Castaneda and Segovia, conducted a tour of physical plant. At 12:38PM LPAs interviewed ten (10) out if 70 randomly selected residents.

Interview revealed that facility retains 10 or more non-ambulatory residents residing on the 2nd,3rd and 4th floor.

The information revealed from the record review supported the information revealed from interviews.
Based on inspection, observation, interviews and record review, there is a sufficient information and evidence to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Exit interview was conducted at which time ED was informed that due to violation of the same Title 22 Regulations within 12 months, additional immediate Civil Penalty of $1000,00 will be issued at the time of this visit.

Exit interview was conducted, appeal rights were discussed, and a copy of report was issued,
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241218135733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARARAT GARDENS
FACILITY NUMBER: 198603605
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
87202
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87202-Fire Clearance -All facilities shall maintain a fire clearance approved by the city fire department..Prior to accepting or retaining.. non-ambulatory persons, the licensee shall notify the licensing agecy and obtain an appropiate fire clearance...
This requirement was not met as evidenced
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The ED will submit a plan for non-ambulatory residents to LPA. As well as request additional non-ambulatory file clearance for the second and third floor residents by submitting LIC 200 within 24 hours.
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by: Upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the 2nd to 4th floor. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
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