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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 02:14:51 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
04/02/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210402105050
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:
02:11 PM
ALLEGATION(S):
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Facility did not seek timely medical treatment for resident.
Facility did not safeguard residents' belongings.
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 did not seek timely medical treatment for resident #1 (R1) as R1 had COVID and was declining not eating, drinking and sleeping all day. R1 was eventually admitted to the hospital severely dehydrated and battling COVID. On 4/7/21 starting at 1:32 pm LPA reviewed R1’s records. The records revealed that on 2/5/21 R1 refused to get out of bed, 02 level was 89% and had a very low appetite having only 3 bites each of breakfast and lunch that day. On 2/10/21 R1’s 02 was dropping staying in the 82 – 85 range. On 2/13/21 R1 was sent out via 911 to the hospital. Staff noted that R1 was short of breath, very
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 6
Control Number 29-AS-20210402105050
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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very restless stating that it was hard to breath. Staff called R1’s family member to see what they wanted, and they asked to have R1 sent out. R1’s hospital records indicate that R1 was admitted to the hospital on 2/13/21 with hypernatremia, acute kidney injury, a complicated urinary tract infection secondary to Kiebsiella pneumoniae, and elevated troponin level. R1 was deemed stable and discharged home on 2/18/21.

On 4/6/21 at 3:49 pm LPA conducted an interview with R1, prior staff and staff on 9/27/22 starting at 4:26 pm, staff on 9/28/22 starting at 8:51 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:51 am. Interviews revealed that staff did not know why R1 was not sent out when their 02 level was in the 82 – 85 range. Staff stated that anything below 90 they should be sent out.

Based on the information obtained, the allegation the facility did not seek timely medical treatment for resident is substantiated at this time.

Concerns were that the facility did not safeguard residents' belongings as R2’s wedding rings, R1’s watch and wallet with a credit card and $40.00 were missing.

On 4/7/21 starting at 12:41 pm LPA reviewed the facilities Theft and Loss policy which indicates that upon admission the resident or the responsible party will be provided with a blank LIC621. Loss of personal property with a value of $25.00 or more will be documented within 72 hours. If the loss exceeds $100 a report will be filed with a Law Enforcement Agency within 36 hours. An incident report will be filed with Community Care Licensing for items that are reported to Law Enforcement. A log of all losses of $25.00 or more will be maintained on the LIC 9060 form. On 9/16/22 starting at 12:59 pm LPA reviewed R1 and R2’s LIC621’s. R1’s LIC621 did not have any items listed and was dated 4/26/18. R2’s LIC621 did not have any items listed and was not signed or dated. LPA did not observe an incident report submitted regarding R1 and R2’s missing items.


Interviews revealed that R2’s rings were placed inside an envelope in a locked staff office by staff due to the ring falling off R2. Staff were aware that that rings were missing, and no one knew what happened to them. Prior Administrator stated that they recommended to the resident’s family member to file a police report and if they did not, they would have. Prior Administrator stated that R1’s wallet was found and given back to R1’s family member. Prior Administrator stated that they did find a watch but R1’s family member stated that it was not R1’s. R1 and R2’s responsible person indicated that a police report was not filed for R1 and R2’s missing items.

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: 2 of 6
Control Number 29-AS-20210402105050
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 the facility did not safeguard residents' belongings is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were 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: 3 of 6
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
04/02/2021 and conducted by Evaluator Joann Rosales
COMPLAINT CONTROL NUMBER: 29-AS-20210402105050

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:
02:11 PM
ALLEGATION(S):
1
2
3
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9
Facility staff did not observe changes in residents' condition.
Resident sustained multiple falls while in care due lack of supervision.
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 staff did not observe changes in resident #1 (R1)’s condition as R1 had COVID was declining not eating, drinking and sleeping all day. On 4/7/21 starting at 1:32 pm LPA reviewed R1’s records. The records revealed that on 2/5/21 R1 refused to get out of bed, 02 level was 89% and had a very low appetite having only 3 bites each of breakfast and lunch that day. On 2/10/21 R1’s 02 was dropping staying in the 82 – 85 range. On 2/13/21 R1 was sent out via 911 to the hospital.

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: 5 of 6
Control Number 29-AS-20210402105050
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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On 4/6/21 at 3:49 pm LPA conducted an interview with R1, prior staff and staff on 9/27/22 starting at 4:26 pm, staff on 9/28/22 starting at 8:51 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:06 am. Interviews with staff revealed that care staff were checking on R1 every 2 hours. Interviews with resident and resident family members did not report any issues with care staff not observing changes in residents’ conditions.

Based on the information obtained, the allegation the facility did not observe changes in residents' condition is unsubstantiated at this time.

Concerns were that Resident #2 (R2) sustained multiple falls while in care due lack of supervision. On 4/8/21 starting at 2:33 pm LPA reviewed R2’s records. The records revealed that R2 had been weak and had falls. R2 had an auto alert fall pendant. R2 refuses assistance with ADL care. R2 had a floor sensor mat and was avoiding it which could be contributing to falls.

On 4/6/21 at 3:49 pm LPA conducted an interview with R1, prior staff and staff on 9/27/22 starting at 4:26 pm, staff on 9/28/22 starting at 8:51 am, and resident, resident family members and prior Administrator on 9/29/22 starting at 9:06 am. Interview with prior Administrator revealed that they recommended moving R2 to memory care so that R2 could be more supervised however, R2’s family member refused. Interview with staff revealed that R2 would move the floor sensor mats and would not use their walker. R2 needed more supervision and was resistant to care. R2 would get up and not call for assistance. Interviews with resident and resident family members did not report any issues with residents sustaining multiple falls due to lack of supervision.

Based on the information obtained, the allegation resident sustained multiple falls while in care due lack of supervision 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: 6 of 6
Control Number 29-AS-20210402105050
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 B
09/30/2022
Section Cited
CCR
87218(a)(3)(c)
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87218 Theft and Loss (a)(3)(c) Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery of the loss or theft and, upon request, the documented theft and loss record for the past 12 months shall be made available to the State Department...
This requirement is not met as evidenced by:
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Facility closed on 7/14/21
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Based on interviews and record review, the licensee did not comply with the section cited above as the licensee did not ensure that R1 and R2's missing items were properly safeguarded and documented in the facility records which poses a potential personal rights risk to persons in care.
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Type B
09/30/2022
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

This requirement is not met as evidenced by:
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Facility closed on 7/14/21
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Based on interviews and record review, the licensee did not comply with the section cited above as incident reports were not completed and submitted to CCL for theft incidents which poses a potential 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: 4 of 6