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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372000400
Report Date: 04/14/2022
Date Signed: 04/15/2022 08:09:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20220407155054
FACILITY NAME:NAZARETH HOUSEFACILITY NUMBER:
372000400
ADMINISTRATOR:PETROSYAN, MILENAFACILITY TYPE:
740
ADDRESS:6333 RANCHO MISSION ROADTELEPHONE:
(619) 563-0480
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:145CENSUS: 87DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Barbara Anne Crowley & Milena PetrosyanTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Licensee did not provide a written notice of rate increase
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced investigation visit to open a complaint investigation regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Chief Executive Officer (CEO) Barbara Anne Crowley. Executive Director Milena Petrosyan arrived during the visit.

During the visit, LPA toured the facility, conducted interviews with facility staff, and reviewed and obtained copies of facility records. The Department’s investigation consisted of interviews with staff and outside sources, review of records, and a tour of the facility. It was alleged that the Licensee did not provide Resident 1’s (R1) responsible party with a written notice of rate increase within two business days. CEO and Executive Director were provided with LIC811 Confidential Names to identify R1. Review of R1’s medical assessment dated 10/7/19 revealed that R1 was diagnosed with mild cognitive impairment and required assistance with bathing.
Continued on LIC9099-C page.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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 08-AS-20220407155054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NAZARETH HOUSE
FACILITY NUMBER: 372000400
VISIT DATE: 04/14/2022
NARRATIVE
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 Review of R1’s care plan dated 11/26/2019 revealed R1 was independent of all care needs except for assistance with self administered medications. Investigative interviews revealed that on 10/19/2021, the Executive Director told R1’s responsible party that staff were assisting R1 in the mornings. Review of facility’s levels of care tool document dated 10/19/2021, R1 was assessed by Executive Director Milena Petrosyan to have mild confusion and forgetfulness, and required verbal reminders to shower, engage in grooming and hygiene activities, and had occasional emotional behaviors. Investigative interviews revealed that between 10/19/2021 and 10/30/2021, the Executive Director and other facility staff discussed R1’s need for Level 2 care with R1’s responsible party via telephone and in-person multiple times. On 10/30/2021, R1’s responsible party received a pro-rated invoice for Level 2 Care services provided from 10/19/2021 to 10/31/2021 and an invoice for November 2021 for room and board and Level 2 Care. Investigative interviews and record review revealed R1’s responsible party was not provided with a written notice of the rate increase due to level of care at that time. Review of facility’s levels of care tool document dated 2/25/2022, R1 was assessed by the Executive Director to be diagnosed with dementia, had moderate confusion, disorientation to time, and required verbal cuing. R1 was also assessed to need hands on assistance for bathing and dressing, was unable to follow exit directions, and required staff to escort R1 to activities and dining. On 2/28/2022, R1’s responsible party received an invoice for March 2022 for room and board and Level 3 Care services. Investigative interviews revealed between 1/1/2022 and 3/1/2022, Administrator and CEO spoke with R1’s responsible party multiple times via telephone and in-person to discuss R1’s need for Level 3 care. R1’s responsible party was not provided with a written notice of the rate increase due to level of care at that time. A sampling of resident records were reviewed and revealed that eight of nine residents' (R1-R9) records did not contain a written notice of rate increase.

Based on the evidence obtained during the investigation, the Department has found that the facility did not provide a written notice to R1’s responsible party regarding the rate increase due to increase in level of care. Therefore, the allegation is deemed substantiated, which means the preponderance of the evidence standard has been met and the allegation is valid. The following deficiency was cited per CA Health and Safety Code Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with CEO Barbara Anne Crowley and Executive Director Milena Petrosyan. A copy of this report and the Licensee's Rights (LIC9058 01/16) were provided to CEO and Executive Director via email. An email receipt confirms the acknowledgement of these documents.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20220407155054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NAZARETH HOUSE
FACILITY NUMBER: 372000400
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited
HSC
1569.657(a)
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1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the ... resident's representative, if any, written notice of the rate increase within two business days after initially providing services...
This requirement has not been met as evidenced by:
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Executive Director will submit a copy of sample rate increase notification letter and copy of written policy to notify responsible parties of rate increases by POC due date.
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Based on interviews and record review, the Licensee did not provide a written notice to the responsible parties of 8 of 9 residents within 2 business days for the level of care increase. This poses a potential personal rights risk to 8 of 9 residents.
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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: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
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