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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604780
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:23:16 PM

Substantiated


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
08/16/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20240816153126
FACILITY NAME:LILOS TENDER SENIOR CARE INCFACILITY NUMBER:
374604780
ADMINISTRATOR:NAZARIAN, ANNIEFACILITY TYPE:
740
ADDRESS:9414 GROSSMONT BLVDTELEPHONE:
(818) 284-2502
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 6DATE:
09/19/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Care Giver Wendy Gomez Estrada.TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff were administering injections to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced complaint investigation visit to gather additional records and deliver findings. The LPA introduced herself and disclosed the purpose of the visit to Care Giver Wendy Gomez Estrada and a spoke on the phone with Licensee Annie Nazaian.

It was reported to Community Care Licensing Division (CCLD) on August 16, 20204 staff were administrating medication injections to a resident.

The licensees and their designated facility staff are limited to “assistance with self-administration” and are prohibited from “administering” medications, unless done so by an appropriately skilled professional acting within their scope of practice. Records reviews indicate that staff members were not authorized to administered medication injections and did not have proper medical authorization or training to administer medication injections.
(continued on 9099-c)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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 4
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
08/16/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20240816153126

FACILITY NAME:LILOS TENDER SENIOR CARE INCFACILITY NUMBER:
374604780
ADMINISTRATOR:NAZARIAN, ANNIEFACILITY TYPE:
740
ADDRESS:9414 GROSSMONT BLVDTELEPHONE:
(818) 284-2502
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 6DATE:
09/19/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Care Giver Wendy Gomez EstradaTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not treat resident with dignity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced herself and disclosed the purpose of the visit to Care Giver Wendy Gomez Estrada and over the phone with Licensee Anna Nazaian

It was reported to Community Care Licensing Division (CCLD) on August 16, 20204 that staff do not treat resident with dignity. LPA Rodgers conducted Interviews with multiple outside sources, staff, and residents and confirm staff were treating residents with kindness, dignity and respect. Reporting party did state they were refering to an outside source that is not associated with the faciliy.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff, resident and outside sources interviews, there is no sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.

An exit interview was conducted in person with Care Giver Wendy Gomez Estrada and over the phone with Licensee Annie Nazaian to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20240816153126
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: LILOS TENDER SENIOR CARE INC
FACILITY NUMBER: 374604780
VISIT DATE: 09/19/2024
NARRATIVE
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(Continued from 9099)

Throughout the investigation, the department inspected the facility, secured pertinent records and conducted interviews with staff, residents, and outside sources. Interviews with outside sources, staff, and resident confirm staff were administering medication injections to their resident.

Based on interviews and records reviewed, a preponderance of evidence exists to show the Licensee did administer injections to their resident. The allegation is therefore substantiated. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A joint plan of corrections was developed with Licensee Annie Nazaian over the phone.

An exit interview was conducted in person with Care Giver Wendy Gomez Estrada and Care Giver Carolina Fuentes and over the phone with Licensee Annie Nazaian to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
Document Link Icon
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20240816153126
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: LILOS TENDER SENIOR CARE INC
FACILITY NUMBER: 374604780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a )A plan.. be developed by each facility. (5)Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited..
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Licensee agreed to provide in service training by an outside vendor to all staff regarding asisstance with self administered medication.
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Based on records review and staff interviews, 1 of 6 clients (C1) used an injection pen device, but Licensee did not ensure that direct care staff were trained on the use of “assistance with self-administration” medications.
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LPA confirmed medicaiton injections were no longer being administered. Licensee will provide a training date to the LPA by 9/20/24. Once training is complete, administrator will send the LPA proof of completion.
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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: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4