Horizon Assisted Living Facility

At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced subsequent complaint visit. LPA met with the staff who granted access to the facility and shorly after Administrator Sona Gevorkyan arrived and LPA disclosed the reason for the visit. A subsequent visit was conducted on 05/22/2024. During course of the investigation, interviews and record review were made. At 12:15 PM, LPA requested resident and staff roster. At 12:20 PM, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 12:35 PM, LPA conducted a physical plant tour. Between 12:45 PM to 2:00 PM, LPA conducted an interview with the Administrator, one staff, four (4) out of five (5) residents who were able to communicate, and a family member of a resident. Additional interviews and record reviews were also conducted during today’s visit. Continue onRead the full finding— CDSS inspection report, July 30, 2024 · control 31-AS-20221228133054

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility on 11/13/2023 to deliver findings. On 06/29/20223 this case was referred to the Community Care Licensing Investigations Branch (IB). Investigator Christine Ferris continued the investigation by conducting records review and interviews on 08/01/23, 08/04/23, and 08/30/23. A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023 and a subsequent visit on 10/31/2023. Staff gave resident unapproved dietary drinks Unsubstantiated— CDSS inspection report, November 13, 2023 · control 31-AS-20230629104943

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 10:10 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was present at the facility. A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023, at which time LPA Smith conducted a physical plant tour at approximately 11:20 am and conducted an interview with the administrator. On 06/29/20223 this case was referred to the Community Care Licensing Investigations Branch (CCIB). Investigator Christine Ferris continued the investigation by conducting records review and interviews on 08/01/2023, 08/04/2023, and 08/30/23. (Cont to 9099C) SubstantiatedRead the full finding— CDSS inspection report, October 31, 2023 · control 31-AS-20230629104943

Licensing Program Analyst (LPA) Tihesha Smith conducted an initial complaint visit to this facility at 10:30 am. LPA Smith met with facility staff and disclosed the purpose of the visit and the administrator arrived later. It was alleged that Facility staff failed to provide resident's records to an authorized representative. LPA Smith conducted physical plant tour at 10:50 AM, interviewed administrator at 11:00 am. Interview with the administrator revealed she did not receive a FedEx letter for R1s records. The administrator revealed she was contacted by telephone on 04/27/23 at 10:24 am from the corporate office requesting R1s records and she sent over 85 pages of records the same day. LPA Smith reviewed the administrators call history and the fax transmittal page dated 04/27/23 indicating 93 pages were sent to the corporate office. LPA Smith also contacted the corporate office at 11:52 am but was unable to get verbal confirmation that the records were received. Based on the informatRead the full finding— CDSS inspection report, April 28, 2023 · control 31-AS-20230421131329

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff Rosa Tonoyan, who contacted administrator Sona Gevorkyan via telephone. Approximately 1:00 pm Ms. Gevorkyan arrived to the facility. Upon arrival LPA conducted a brief tour of the facility and spoke with Staff. While conducting the tour LPA observed the 2 backyard gates exiting the facility pad locked. 1 of the 2 gates is not used as an exit. Regarding the allegation listed above, concerns of Neglect/Lack of Care resulting in Resident 1 (R1) developing multiple pressure injuries while living at the facility were reported. This investigation was conducted by Olivia Spindola, Investigator with Community Care Licensing Division’s Investigations Branch (IB) and Licensing Program Analyst (LPA) Yelena Avetisyan. Continued on 9099 (c) SubstantiatedRead the full finding— CDSS inspection report, June 25, 2022 · control 31-AS-20200428160827

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with the administrator, Sona Gevorkyan, and explained the reason for the visit. --- Resident’s needs are not being met. It was alleged that the resident is deteriorating fast. To investigate this allegation, on 06/01/2020, LPA Martina Berry interviewed staff, responsible party and complainant. On 06/08/2022, LPA Abeye Duguma interviewed residents and requested the resident’s file. Interviews and record review revealed that staff are meeting the needs of Resident #1 (R1), that R1 suffered from a stroke and was diagnosed with dementia which can alter behavior as the resident’s health deteriorates. Based on interviews and record review, the allegation is unsubstantiated at this time. (cont. on LIC9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, June 8, 2022 · control 31-AS-20200521115717

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff .Svetlana Petrosyan and Volunteer Anush Danelyan. Ms. Petrosyan contacted administrator Sona Gevorkyan via telephone. LPA spoke with Ms. Gevorkyan who stated she is far from facility and would not be able to come for the visit. Ms. Gevorkyan designated Ms. Petrosyan to sign for the report. Regarding the allegation listed above, it is being alleged that the R1 was admitted to the hospital twice in less than one month. Upon the 03/23/2021 admission to the hospital, concerns of neglect were reported due to pressure injuries. This investigation was conducted by Douglas Real, Investigator with Community Care Licensing Division’s Investigations Branch (IB). On 5/12/2021, Investigator Real conducted a review of Kaiser Permanente medical records. Additionally, on various days from 05/12/2021 to 06/24/2021 Investigator Real conducted interRead the full finding— CDSS inspection report, April 7, 2022 · control 31-AS-20210326092829

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit. Upon entry LPA conducted a physical plant tour from 9:45-10am to ensure no immediate health and safety issues. It is alleged that facility used postural supports inappropriately. It is alleged that staff use a gait belt on residents at night so they cannot move. LPA conducted interviews with residents from 10:45-11:30am. LPA conducted interviews with facility staff from 11:30-12pm regarding this allegation. LPA also reviewed resident files from 10:00-10:30am. Information revealed that resident #1 (R1) was prescribed a half bed rail but at night another half bed rail was put up in addition to the half bed rail R1 was already using. Based on the information obtained from record review and interviews this allegation is deemed Substantiated. Staff used half bed rail inappropriately. Deficiency citRead the full finding— CDSS inspection report, March 22, 2022 · control 31-AS-20220321131259

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to this facility to investigate the above allegation. The investigation consisted of a physical plant inspection, interviews and record review. Per interviews and record review, the investigation reveals each resident interviewed had no complaints or concerns regarding facility service. The residents that were interviewed stated they are never mistreated by staff. Residents stated that they are also treated with respect. When residents were asked if they've ever witnessed any of their peers being mistreated, they all stated no. Interviews with staff also do not corroborate with the allegation. Review of Resident 1's (R1) record indicates some confusion/disorientation that may need some orientation. Based on the information obtained, there was insufficient evidence to confirm staff are mistreating a resident in care. Therefore, the allegation is deemed Unsubstantiated at this time. UnsubstantiatedRead the full finding— CDSS inspection report, March 8, 2022 · control 31-AS-20220301141750