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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800683
Report Date: 09/30/2022
Date Signed: 09/30/2022 04:31:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210625141736
FACILITY NAME:AEGIS OF VENTURAFACILITY NUMBER:
565800683
ADMINISTRATOR:BASSEM EL-RABAAFACILITY TYPE:
740
ADDRESS:4964 TELEGRAPH ROADTELEPHONE:
(805) 650-1114
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:0CENSUS: DATE:
09/30/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karen Gary GoroyanTIME COMPLETED:
02:41 PM
ALLEGATION(S):
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Resident needs are not met due to staffing shortage
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced subsequent complaint visit to deliver investigation findings. The facility Aegis of Ventura closed and had a change of ownership effective July 14, 2021. Today's inspection was conducted at the newly licensed facility Aegis Living Ventura #565850141. The LPA met with current Administrator Karen Gary Goroyan. Administrator stated that they can review and sign reports on behalf of Aegis of Ventura.

Concerns were that resident #1 (R1) needs are not met due to staffing shortage. On 7/1/21 starting at 10:19 am LPA conducted an interview with resident family member, prior staff and staff on 9/27/22 starting at 4:45 pm, staff on 9/28/22 starting at 8:40 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Based on interview with R1’s family member R1 was supposed to be turned every 2 hours and on 6/29/21 staff did not go in to turn R1 for 3 hours and 10 minutes. Interview with R2’s family member revealed that R2 complained that they were being left soiled in a depends for a long period of
Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
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 7
Control Number 29-AS-20210625141736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS OF VENTURA
FACILITY NUMBER: 565800683
VISIT DATE: 09/30/2022
NARRATIVE
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time. R2’s family member stated that they tested R2’s call button when they visited R2 and it took 30 to 40 minutes for staff to respond.

Based on the information obtained, the allegation that resident needs are not met due to staffing shortage is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):



Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator Karen Gary Goroyan.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210625141736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AEGIS OF VENTURA
FACILITY NUMBER: 565800683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited
CCR
87464(f)(1)
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87464 Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Facility was closed effective 7/14/21
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Based on interviews and record review, the licensee did not comply with the section cited above as residents were not being changed and turned timely which poses a potential health and personal rights risk to persons 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210625141736

FACILITY NAME:AEGIS OF VENTURAFACILITY NUMBER:
565800683
ADMINISTRATOR:BASSEM EL-RABAAFACILITY TYPE:
740
ADDRESS:4964 TELEGRAPH ROADTELEPHONE:
(805) 650-1114
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:0CENSUS: DATE:
09/30/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karen Gary GoroyanTIME COMPLETED:
02:41 PM
ALLEGATION(S):
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Facility failed to report cases of COVID 19
Facility is in disrepair
Resident is unable to communicate with family members
Staff did not respond to resident in a timely manner when choking
Resident was left in soiled clothing for an extended period of time
Resident sustained injuries due to unwitnessed fall(s)
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced subsequent complaint visit to deliver investigation findings. The facility Aegis of Ventura closed and had a change of ownership effective July 14, 2021. Today's inspection was conducted at the newly licensed facility Aegis Living Ventura #565850141. The LPA met with current Administrator Karen Gary Goroyan. Administrator stated that they can review and sign reports on behalf of Aegis of Ventura.

Concerns were that the facility failed to report cases of COVID 19 as R1’s responsible person was not notified that R1 was COVID positive. On 9/27/22 starting at 4:45 pm LPA conducted an interview with prior staff and staff, staff on 9/28/22 starting at 8:40 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Interviews revealed that R1’s responsible person was notified the day after R1 tested positive for COVID. Resident family members interviews revealed that they were notified verbally and by emails regarding COVID positives in the facility. Interview with prior Administrator revealed that they had
Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20210625141736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS OF VENTURA
FACILITY NUMBER: 565800683
VISIT DATE: 09/30/2022
NARRATIVE
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taken upon themselves to call family members when a resident tested positive for COVID. They also stated that they would send out letters to all families by email and distribute by hand to residents in the facility regarding COVID positives in the facility.

Based on the information obtained, the allegation that the facility failed to report cases of COVID 19

is unsubstantiated at this time.

Concerns were that the facility is in disrepair as a fire sprinkler fell out of the ceiling in resident #1 (R1)’s room and hit the floor.

On 7/2/21 starting at 3:52 pm LPA took photos during the facility visit of the fire sprinklers on the ceiling in the hallway right outside of R1’s room and in R1’s room and bedroom hallway which appeared to be in working order not falling from the ceiling. Based on LPA’s observations the fire sprinklers did not appear to be repaired.



On 7/1/21 starting at 10:19 am LPA conducted an interview with resident family member, prior staff and staff on 9/27/22 starting at 4:45 pm, staff on 9/28/22 starting at 8:40 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Based on interviews there was no corroboration that a fire sprinkler fell out of the ceiling in R1’s room and hit the floor.

Based on the information obtained, the allegation that the facility is in disrepair is unsubstantiated at this time.

Concerns were that resident #1 (R1) is unable to communicate with family members as the General Manager limits the contact with R1’s family members.

On 7/1/21 starting at 10:19 am LPA conducted an interview with resident family member, prior staff and staff on 9/27/22 starting at 4:45 pm, staff on 9/28/22 starting at 8:40 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Based on interviews R1’s family did not have issues with communicating with R1 as they would call ahead and schedule a time to visit. Resident family members stated that they did not have any issues with communicating with family members as the facility provided virtual Facetime and zoom visits, outdoor visits with plexi-glass and microphones.

Continued on 9099C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20210625141736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS OF VENTURA
FACILITY NUMBER: 565800683
VISIT DATE: 09/30/2022
NARRATIVE
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Based on the information obtained, the allegation that resident is unable to communicate with family members is unsubstantiated at this time.

Concerns were that staff did not respond to resident #1 (R1) in a timely manner when choking on 6/22/21.

On 7/1/21 starting at 10:19 am LPA conducted an interview with resident family member, prior staff and staff on 9/27/22 starting at 4:45 pm, staff on 9/28/22 starting at 8:40 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Interviews with prior Administrator and staff stated that they do not recall R1’s 6/22/21 choking incident where staff did not respond timely. Interview with prior Administrator revealed that the staff were very aware of R1. Prior Administrator stated that R1 did not take water on their own or anything on their own. Prior Administrator stated that if R1 choked the staff were there. Interview with R1’s family member revealed that they were not aware of R1 having a choking incident on 6/22/21. Interviews with resident family members revealed that they are not aware of staff not responding timely to residents when choking.

A review of R1’s records on 9/16/22 starting at 3:07 pm does not reflect a choking incident on 6/22/21.

Based on the information obtained, the allegation that staff did not respond to resident in a timely manner when choking is unsubstantiated at this time.

Concerns were that resident #1 (R1) was left in soiled (vomit) clothing for an extended period of time.

On 7/1/21 starting at 10:19 am LPA conducted an interview with resident family member, prior staff and staff on 9/27/22 starting at 4:45 pm, staff on 9/28/22 starting at 8:40 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Interviews with prior Administrator, staff and R1’s family member revealed that they do not recall an incident where R1 was left soiled in vomit for an extended period of time. Interviews with resident family members revealed that they are not aware of any residents being left soiled in vomit for an extended period of time.

Based on the information obtained, the allegation that resident was left in soiled clothing for an extended period of time is unsubstantiated at this time.

Continued on 9099C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210625141736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS OF VENTURA
FACILITY NUMBER: 565800683
VISIT DATE: 09/30/2022
NARRATIVE
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Concerns were that resident #1 (R1) sustained injuries due to unwitnessed fall(s).

On 7/1/21 starting at 10:19 am LPA conducted an interview with resident family member, prior staff and staff on 9/27/22 starting at 4:45 pm, staff on 9/28/22 starting at 8:40 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Interviews with prior Administrator, staff and R1’s family member revealed that they do not recall an incident where R1 sustained injuries to due to unwitnessed falls. Interviews with resident family members revealed that they are not aware of any residents sustaining injuries due to unwitnessed falls.

On 9/16/22 starting at 4:38 pm LPA reviewed R2’s records. The records revealed that R2 had a motion sensor and bed/chair alarm.

Based on the information obtained, the allegation that resident sustained injuries due to unwitnessed fall(s) is unsubstantiated at this time.

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator Karen Gary Goroyan.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7