Wellbe Home

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Karine Simonyan, Staff. Vahe Mkrtchian was contacted by staff and he arrived a little later to conduct the visit. Also present during this visit was Lala Karapetyan, Staff. The reason for today's visit was provided. The facility is a single storey home consisting on a living room, a kitchen, a dining room, 5 bedrooms, 3 full bathrooms and a detached garage located at the back of the property. Part of the garage has been converted to an office and part of the garage is used for storage. The facility is fire cleared for 5 non-ambulatory and 1 bedridden. However, at the request of the Licensee, the facility is licensed for a total of 4 residents of which 1 may be bedridden. Any of the resident bedrooms may be used for the bedridden resident. The following were observed on today's visit: The living room, dining room, kitchen have the appropriate furnishings and equipment. The only fire extinguisher purchased on 6/27/23 is located in the kitchen The four resident bedrooms contained a bed, a chair, a night stand, a lamp, a dresser and a closet. The beds were observed with a mattress cover, a fitted sheet and a blanket or a comforter. Per the Administrator, it is hot and the residents do not want to use a comforter and they were observed stored in the closet. A couple of fitted sheets and 1 flat sheet each were observed in the residents' dressers. The blinds in bedroom #3 was observed to be loose and could not be shut completely. Medications are centrally stored in a locked closet by the staff bedroom The 3 full bathrooms were toured. Bedroom #4 has a full bathroom installed with a shower, a toilet, a sink. Grab bars, shower chair and non-skid mat was observed. The water was tested and read 116.2 degrees Fahrenheit. The 2 common bathrooms are located in the hallway by the resident bedrooms. The common bathroom located by bedroom #3 is designated for staff use. It has a shower, toilet and a sink. The common bathroom located directly in front of kitchen is equipped with a shower, a toilet and a sink. Grab bars and non-skid mats and shower chair were observed. Water temperature tested read 118.2 degrees Fahrenheit. Food supplies were reviewed. Observed in the refrigerator were a couple of plastic containers with watermelon, 3 green bell peppers, 1 red bell pepper and two full 32 oz cartons of milk and a 1/3 quart of bottle of milk. Located in the pantry were 3 bananas and 4 apples. Snacks and breakfast foods were not observed Insufficient non-perishables were observed in the kitchen and consisted of small cans of soups and vegetables were observed. No pastas, sauces or rice were observed to make a balanced meal for 7 days. Snacks were low. Per Administrator, they are going marketing on Thursday.. Cleaning supplies are stored in a locked cabinet under the kitchen sink The first aid kit was reviewed and contained gauzes, tapes, tweezer and scissors. The facility has a common thermometer. No first aid manual was observed. The hardwired combination smoke/carbon monoxide detectors were tested and were operational. The washer and dryer located outside the kitchen was observed in use and was operational Per tour of the backyard, a gazebo with a table and 6 chairs were observed. Trash cans were tightly sealed. The front yard was observed to be clean. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.the state’s words, verbatim · CDSS document, Sep 20, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA initially met with staff, whom contacted the Administrator. The LPA spoke with Administrator Vahe Mkrtchian over the phone, whom arrived shortly thereafter. The LPA, along with staff, toured the facility to ensure there were no immediate health and safety hazards. The facility is vendored through North Los Angeles Regional Center (NLARC) as a level 3 home. The LPA spoke with residents during the tour; residents appeared satisfied and voiced no concerns. KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: There are five rooms total; four private resident rooms and one designated staff room. Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The three restrooms were clean and sanitary with grab bars and non-skid surfaces. At 12:50 p.m., water temperature measured at 112.3 F. Restrooms were stocked with soap and paper towels. COMMON SPACES: The facility maintained a temperature of 73 degrees. Medications were kept locked in a hallway closet, which also had additional supplies. Smoke detectors and carbon monoxide detectors were operable. Living room and dining furniture were observed in good condition. Fire extinguisher was purchased June 2022. The backyard and exterior area of the facility had furniture and a covered area for resident use. No obstructions observed in the exterior or interior. No bodies of water noted. The garage is detached and was equipped with a large supply of Personal Protection Equipment (PPE). Resident and staff files are in the locked office, which is adjacent to the garage. INFECTION CONTROL: There is a central entry point for screening and temperature checks. Appropriate infection control signage was observed throughout the facility. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The Department’s Provider Information Notices (PINs) were posted. The facility continues to conduct weekly surveillance testing. The policies and procedures pertaining to infection control were adequate. No deficiencies cited. Exit interview conducted. Report issued.the state’s words, verbatim · CDSS document, Aug 7, 2022

Allegation investigated: Failure to contain records of resident's cash resources as specified

Licensing Program Analyst (LPA) Salia Walker arrived unannounced to deliver the findings for the above allegation. Upon entry, the LPA was greeted by staff. At 9:19 a.m., the LPA contacted Administrator Vahe Mkrtchian, and entrance interview was conducted. On 03/23/22, LPA Walker conducted an unannounced initial complaint inspection. During the visit, the LPA conducted a physical plant tour with the administrator. From 11:27 a.m. until 11:55 a.m., the LPA conducted an interview with the administrator. From 11:55 a.m. until 12:37 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 12:37 p.m. until 1:55 p.m., the LPA along with the Administrator reviewed four (4) out of four (4) client medications. From 2:08 p.m. until 2:46 p.m., the LPA conducted interviews with three (3) out of four (4) facility clients. From 2:46 p.m. until 2:56 p.m., the LPA conducted interviews with staff. The LPA determined further investigation was needed at that time. Continue on LIC9099C.. Substantiated Regarding the allegation, ‘Failure to contain records of resident's cash resources as specified,’ it is alleged that the facility failed to update clients’ P and I files since October 2021. On 03/16/22, interview(s) revealed that an outside agency credible witness visited the facility; and during the visit, the Administrator provided receipts, and advised that the facility would be updating the clients P and I’s as the facility fell behind. During the investigation, LPA Walker conducted a record review, and interview with the administrator. Record review revealed that three (3) out of four (4) client P and I files were up to date. Record review also revealed that client purchase receipts were accurate, and numbered. Interview with the Administrator revealed that facility client’s cash resources in the P and I book had not been updated for a few months. The administrator acknowledged the facility failed to follow regulation and keep clients P and I’s updated, as they ‘got busy, and fell behind.’ The Administrator also stated that the facility has since then implemented the suggested record keeping order from Regional Center since the last visit. Based on record review and interviews which were conducted, there is sufficient evidence to support the allegation ‘Failure to contain records of resident's cash resources as specified.’ Therefore, the above allegation is found to be Substantiated at this time. Pursuant to Title 22 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 issued. Regarding the allegation, ‘Staff did not assist residents with self-administered medications as prescribed,’ it is alleged that facility clients’ medication count was off. It was also alleged that the facility staff did not have a sequence in which medication bubble packs were distributed. Therefore, there was concern that clients were not being assisted with the self-administration of medication as prescribed. On 03/16/22, interview(s) revealed that an outside agency credible witness visited the facility; and during the visit, three (3) out of four (4) client medications were reviewed. The interview(s) also revealed that during the medication review, there was no sequence in the bubble packs for the three (3) clients. Credible witness also noted the facility started backwards from the end of the month, and on the 20th for one month there was one (1) pill that was not punched. According to the credible witness, the explanation that was given was that the facility received a ‘new batch’ on the 27th. However, the credible witness could not confirm, as allegedly the medication count was still off. During the investigation, LPA Walker conducted interviews with the administrator, facility clients, staff, and conducted a medication audit. Interview with the administrator revealed that all clients are assisted with the self-administration of their medication on time. The administrator admitted to not having a set sequence in which the medication bubble packs were ‘popped.’ However, denied any medication being missed or staff not assisting clients with self-administered medications as prescribed. Interviews with facility staff revealed that no medication has been forgotten to be provided to clients. Interviews with facility clients revealed that staff have not forgotten to assist clients with self-administration of their medication. Interviews with facility clients also revealed that staff are ‘timely;’ and if staff are running behind due to cooking during lunch, clients remind them within ‘5 minutes.’ Medication audit conducted by LPA Walker along with Administrator Vahe Mkrtchian revealed that four (4) out of four (4) client medications were accurate, and accounted for. Based on record review, interviews with the administrator, facility staff, and clients, although there may have been times when client’s medication bubble packed were popped out of sequence. The facility staff have been retrained in following a sequence, and no medication was missing. Therefore, there is insufficient evidence to support the allegation ‘Staff did not assist residents with self-administered medications as prescribed.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted and a copy of the report was emailed.the state’s words, verbatim · CDSS document, May 27, 2022 · control 29-AS-20220316162717

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80026(h) · Plan of correction due date: Jun 3, 2022

80026(h) Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources... entrusted to his/her care, including, but not limited to the following: This requirement was not met as evidenced by: Based on interviews conducted, the licensee did not comply with the section cited above, as the facility failed to ensure clients P and I records were up to date, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: The Licensee agreed to the following: 1.Submit a statement of understanding of section 80026(h) to CCL by 06/03/22.

Type of visit: Office

An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss deficiencies cited during a required annual visit on 8/10/2021, specifically to discuss the LPA’s observation during the visit where a resident was locked in bedroom #2; the doorknob was tampered with so the resident could not exit the room. In attendance included Licensing Program Manager Jeralyn Pfannenstiel, Licensing Program Analyst Salia Walker, and Administrator Vahe Mkrtchian. Brief History: The facility was first licensed in 9/19/17, for a capacity of six residents. LPM Pfannenstiel and LPA Walker discussed unsubstantiated complaint allegations from the past three years related to personal rights violations from 1/4/2018, 5/18/2018, 4/15/2019, 9/25/2020, and 1/7/2021. LPM and LPA communicated that the Department has received the Plan of Corrections in a timely manner, which included documentation for staff association, and photographs of proper doorknob. LPM Pfannenstiel discussed how the Administrator plans to stay in compliance and the best ways to work with the Department and Regional Center for additional support and assistance. The Administrator stated that the facility now has rotating staff to ensure sufficient staffing is available. The Licensee was informed that Community Care Licensing (CCL) shall continue to monitor the facility with annual facility inspection visits and as often as necessary to ensure the Licensee's compliance with Title 22 Regulations. The Licensee was also informed that further citations and/or non-compliance may result in a Non-Compliance Conference with the Regional Manager. Exit interview conducted and copy of today's report was provided to the Licensee.the state’s words, verbatim · CDSS document, Aug 26, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a Required Annual visit at 09:12 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Vahe Mkrtchian at 09:27 a.m., and explained the reason for the visit. When LPA Walker was knocking at the front door at 09:12 a.m., the LPA heard knocking coming from inside the facility. Upon entry at 09:21 a.m., LPA Walker met with the only staff present in the facility, caregiver #1. Upon review of the facility personnel report summary, the LPA observed that caregiver #1 is not associated with the above facility. The LPA then focused on the knocking sounds coming from room #2. The LPA advised caregiver that the knocking appeared to have been continuing since 09:12 a.m. The LPA asked the caregiver to ensure that the resident was not in any distress. Resident #1 (R1), who was exiting their room at the time, stated that resident in room #2 always knocks on the door and that the knocking never ends. At 09:23 a.m., the LPA observed that Room #2 appeared to be locked. Caregiver #1 stepped away to retrieve a key, which was utilized to turn the lock on the doorknob and unlock the door to room #2. Resident #2 (R2) stepped out of room #2 and sat on the couch. The LPA asked why room #2 door was locked. Caregiver #1 stated that R2 always tries to get out. Caregiver #1 also stated that R2 tries to get away gesturing with hand he tries to exit the facility. The LPA checked the doorknob and confirmed that the door was locked from outside room #2, and that R2 had no way to exit. The LPA also observed room #2 had an emergency exit door which was also locked and inaccessible. At 09:25 a.m., caregiver #2 arrived at the facility. At 09:25 a.m., the LPA also received a telephone call from the administrator to inform the LPA of the anticipated time of arrival. The LPA advised the administrator of room #2 being locked. The administrator stated that R2 locks the door from the inside. The LPA advised the administrator that the LPA checked the door from inside and confirmed there was no way to lock the doorknob from inside the room as the lock piece had been removed. (Photos were taken by the LPA). The LPA advised the administrator of the statements caregiver #1 made. Continue on LIC 809C.. At 09:27 a.m., the administrator arrived at the facility. The LPA advised the administrator the locked door was a Personal Rights Violation, as well as a Fire Safety/Clearance Violation. The LPA advised the administrator of the immediate Health and Safety risk the locked door poses to any resident, but especially to R2, due to a diagnosis of Epilepsy. The administrator stated the facility ordered a new doorknob, and that the reason for the current doorknob was due to R2 breaking other doorknobs. The LPA toured the physical plant areas inside and outside to ensure there are no other health and safety hazards at 09:52 a.m. BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Restroom one (1) hot water measured 113.6 Fahrenheit at 09:56 a.m. Restroom two (2) hot water measured 116.4 Fahrenheit at 10:06 a.m. Restroom three (3) hot water measured 117.3 Fahrenheit at 10:07 a.m. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 114.1 Fahrenheit at 10:12 a.m. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the kitchen, with the exception of CDSS PINs which the LPA advised the administrator must be printed and displayed for staff and residents. One fire extinguisher was observed to be fully charged and purchased on 07/28/2021. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The Laundry area is located in the backyard. The garage is detached to the facility. The garage contains additional nonperishable and perishable food items. At 10:16 a.m., the LPA observed insufficient amount of emergency water for facility. Administrator stated facility will purchase sufficient emergency water. Continue on LIC 809C.. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil Penalties were issued (See LIC 421). Exit interview conducted. A copy of the report and appeal rights were provided via email..the state’s words, verbatim · CDSS document, Aug 10, 2021