374604490-2-2-2024-08-AS-LTEZ-D2VTZK-20240228141024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604490
Report Date: 02/02/2024
Date Signed: 02/02/2024 12:55:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
01/30/2024 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20240130163437

FACILITY NAME:	COLLEGE TOWN SENIOR RETIREMENT VILLA INC		FACILITY NUMBER:	374604490
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	5252 STONE CT		TELEPHONE:	(619) 432-1236
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	6	CENSUS: 6	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	11:19 AM
MET WITH:	Nvard Bebekyan, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to open a complaint and deliver findings regarding the above-mentioned allegation LPA was allowed entry by Nvard Bebekyan, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Administrator.

On January 30, 2024, the Department received a complaint that: resident sustained unexplained bruising while in care. The Department investigated the complaint allegation. The investigation consisted of a tour of the facility, an interview with staff and residents, and a records review.

The complainant did not provide any specific information regarding the allegation. A review of records indicated that Resident 1 (R1) is non-ambulatory and required a two-person assist to be transferred due to limited mobility and weakness on one side of the body. Staff and residents were interviewed and did not witness any willful neglect that would cause unexplained bruising while in care.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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 08-AS-20240130163437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: COLLEGE TOWN SENIOR RETIREMENT VILLA INC	FACILITY NUMBER: 374604490
	VISIT DATE: 02/02/2024

NARRATIVE

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There was insufficient evidence found to support the allegation that: Resident sustained unexplained bruising while in care. Due to a lack of evidence, the allegation is deemed to be unsubstantiated. An unsubstantiated finding means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Nvard Bebekyan, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and her signature on this report confirms receipt of the Licensee Rights.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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