Age Well Assisted Living Facility

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Zabel Chochian generated a Case Management - Deficiencies visit report during the investigation of Complaint Control #29-AS-20240501152412. Reason for this report is to issue deficiency observed during the complaint investigation which were unrelated to the complaint allegation. During the physical plant tour, LPA Chochian observed full rails on four (4) resident (R) beds (R1, R2, R3, and R4). LPA asked staff if the full bed rails are used and staff stated yes. Staff confirmed that currently there are no residents on hospice. The following deficiency was 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. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, May 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(5)(B) · Plan of correction due date: May 8, 2024

Postural Supports (5) (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, the licensee failed to comply with the section cited above. Four out of five residents (not on hospice) observed with full rails on the beds; staff confirmed the use of the full rails. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2024

Plan of correction: The Licensee/administrator shall submit proof by 05/08/2024 to CCL that the bed rails for all four residents have been removed (submit photo) or submit proof that residents are receiving hospice services and have an order for a full bed rail.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240416124733). LPA met with Elena Kordonsky and explained the reason for the visit. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. During the complaint investigation, LPA conducted a Residents records review at approx 10:30am and revealed that the facility does not maintain accurate resident records. Two (2) out of Five (5) resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(F) · Plan of correction due date: Apr 26, 2024

87506(b)(F) Each resident’s record shall contain at least the following information...(17) documents and information...(F)Section 87505, Documentation and support. This requirement was not met as evidenced by: Based on records review two (2) out of five (5) resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee agreed to maintain full resident files in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 04/26/2024.

Type of visit: Case Management - Other

On 03-18-2024, Licensing Program Analyst (LPA) Brian Balisi met with Sarkis Dovlatyan for an unannounced Case Management visit to issue a civil penalty per Health and Safety Code §1569.49(f). On January 31, 2023, the Department received a complaint alleging facility staff lack of care and supervision resulted in a resident (R1) eloping from the facility multiple times. On June 21, 2023, the allegation was substantiated, and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, Section 87464(f)(1) Basic Services due to a lack of care and supervision which resulted in R1 eloping from the facility on multiple occasions and sustaining serious injuries. An immediate civil penalty of $500 was also assessed for a violation of CCR Title 22, Section 87464(f)(1) Basic Services. The licensee was also informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injury while under the care of this facility. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee’s failure to provide adequate care and supervision, resulting in R1 eloping from the facility last on February 6, 2023. The resident was struck by a motor vehicle and sustained multiple rib fractures and a hematoma to forehead. Today, 03/18/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. Continued from 809 A copy of the LIC 421D was given to Sarkis Dovlatyan and originals were signed. Exit interview conducted. A copy of the report was issued. Appeal Rights provided. Sarkis Dovlatyan signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Mar 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.317 · Plan of correction due date: Mar 29, 2024

1569.317 Absentee notification plan for missing residents. Every residential care facility... missing from the facility...shall notify local law enforcement when a resident is missing from the facility. This requirement is not met as evidenced by: Based on (interview/record review) the licensee did not comply with the section by not implementing an absentee notification plan for missing resident, which is a potential health, and safety concerns to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2024

Plan of correction: Licensee agreed to review regulation cited and submit statement of understanding to LPA via email by 03/29/2024 EOD.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility. Upon arrival LPA met with head caregiver Zhyparkul Mursamambetova and explained the reason for the visit. Assistant Administrator Elena Kordonsky arrived shortly after. A tour of the physical plant was conducted with administrator approximately between 10:30am - 12:00pm LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: A tour of the physical plant was conducted. The facility has three (3) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bathroom is designated for staff use only. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings in the living area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. At approximately 11:15am the LPA observed non-perishable items in poor condition – Carrots (expired 07/09/2023), Pasta Sauce (expired 01/04/2023). Sharp objects are stored in a locked drawer to the right of the dishwasher. Medication is stored in a locked cabinet above the dishwasher. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Continued from 809 Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom Residents have sufficient amounts of supplies for personal hygiene stored in the designated staff bathroom. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit in all bathrooms during visit. Laundry area was located in the staff bathroom as well. Cleaning supplies were observed stored in locked cabinets located in staff bathroom inaccessible to residents in care at this time. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. There was an Adult Dwelling unit located in the rear of the facility. LPA observed unit to be empty at this time and inaccessible to residents care. LPA observed storage unit to the left of the home. Storage unit was observed to store extra furniture, hardware and other items for facility use. The property is gated with a motorized gate leading into driveway.There is an entry way gate for client use and is single latched. No bodies of water noted at this time. Medications: Medications review began at 11:50am The medications are centrally stored in a locked cabinet above the microwave. LPA reviewed medications for the (4) residents in care. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Records: LPA began reviewing Personnel and Resident Records at 01:20pm. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Continued from 809-C Two (2) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At 1:40pm, LPA observed that Staff 1 (S1) did not have a CPR First Aid Card on file and Licensee / Care Provider Sarkis Dovlatyan CPR First Aid card was expired. Personnel files for Administrator Khatchik Danielian and Assistant Administrator Elena Kordonsky were not observed on site at this time. LPA interviewed Staff at approximately 3pm. LPA attempted to interview residents at 3:15pm, but (3) residents were sleeping and (1) declined to interview. During today’s visit, the LPAs obtained copies of the following: staff roster, staff schedule, and resident roster. 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. Exit interview conducted, appeal rights discussed and copy of report provided.the state’s words, verbatim · CDSS document, Jul 18, 2023

Allegation investigated: Lack of supervision resulting in resident eloping from facility Facility did not report resident missing in a timely manner

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver findings for the above allegations. Upon arrival LPA met with staff. Staff contacted Licensee Sarkis Dovlatyan who arrived shortly after LPA. Reason for visit was explained. Shortly after, staff Elena Kordonskiy arrived to the facility. Following complaint investigation was reviewed with Mr. Dovlatyan and staff E. Kordonskiy: On 02/07/2023, the initial complaint visit was conducted by LPA Balisi between approximately 9:30 a.m. – 12 p.m. During the visit. LPA conducted a tour of the physical plant, interviewed staff, responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/21/2023, at approximately 9:45 a.m., LPAs Balisi and Chochian conducted physical plant tour, interviewed residents, and staff, as well as reviewed and obtained additional pertinent documents relevant to the investigation. During the course of the investigation, Calls for Service records were also obtained from Los Angeles Police Department (LAPD). On 06/21/2023 and 06/29/2023 additional interviews were conducted with the family of Resident #1 (R1). (continue to LIC9099c) Substantiated It was alleged that lack of supervision resulted in R1 eloping from the facility and the facility failed to report R1’s elopement in a timely manner. Information gathered reflected that R1 has a diagnosis of Dementia and was admitted to the facility on 11/22/2022. R1 only resided at the facility for seven (7) days and was relocated to a different facility. Interviews conducted and records reviewed revealed that R1 eloped from the facility at approximately 7:00 a.m. on 11/25/2022. Interviews further reflected that the family of R1 was not contacted by facility staff and was unaware that R1 eloped from the facility until the family was notified by LAPD. Based on LAPD records, on 11/25/2022 at 10:48 a.m., law enforcement was notified of R1 missing from facility. It was notated that R1 was last seen one and half hours ago, suffers from Alzheimer’s, and was new to the facility. Law enforcement began a search for a missing person and at 12:11 p.m., additional units were requested for “Critical Missing” person. An “Official Adult Teletype” was created at 2:24 p.m. for a missing person with the public to contact LAPD with any information. R1 was located on 11/28/2022 at 3:54 p.m. and was transported to the hospital. Moreover, the family of R1 was informed that additional staffing will be hired as an extra safety precaution however, R1 subsequently eloped twice after. Interviews conducted with staff reflected that staff were not able to recall R1 nor, any elopements related to R1. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision R1 eloped from the facility and that facility failed to report R1’s elopement in a timely manner; therefore, the above allegations are deemed SUBSTANTAITED at this time. Pursuant to Title 22 the following citations were issued. (Refer to LIC9099-D) Exit interview was conducted. Citations issued/ A copy of report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2023 · control 29-AS-20230202134526

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 30, 2023

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews and records reviewed Licensee did not ensure supervision was provide to R1; as result R1 eloped from facility.the state’s words, verbatim · CDSS document, Jun 29, 2023

Plan of correction: Licensee stated that he has terminated staff since the multiple elopement incidents at the facility. Furthermore, Licensee agrees to review with staff current residents care plan and ensure proper supervision is provided for residents. Submit self certification letter for the above by 06/30/2023. In addition, Licensee shall provide an updated LIC500 - Personnel Schedule showing sufficient staff coverage based on residents care needs. Also submit copy of in-service training provided to staff. Submit by 6/30/2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jul 3, 2023

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8)To have their representatives regularly informed by the licensee of activities related to care..... This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, Licensee did not report R1 missing in a timely manner.the state’s words, verbatim · CDSS document, Jun 29, 2023

Plan of correction: Licensee agreed to review section cited and provide how they will ensure this requirement is followed. Provide a self certification letter to the department by 07/03/2023.

Allegation investigated: Lack of supervision resulting in resident eloping from facility. Staff not properly managing resident's medication.

Licensing Program Analysts (LPA)'s Brian Balisi and Zabel Chochian conducted a subsequent complaint visit to further investigate the allegations listed above and issue final report. Upon arrival, LPAs met with staff Zhyparkul Mursamambetova and explained the reason for the visit. Administrator Sarkis Dovlatyan arrived shortly after. On 1/31/2023, the Department receive a complaint alleging that Resident #1 (R1) had eloped from the facility six (6) times. In addition, it was further alleged that facility staff reported that R1s medication (name of med) needs to be refilled. However, per the RP, the medication staff referred to was not prescribed to R1. On 02/02/2023, the initial complaint visit was conducted by LPA Balisi approximately between 9:30 a.m. – 11:30 a.m. During the visit, LPA conducted physical plant tour, interviewed residents, staff, responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 02/15/2023, Investigation Branch (IB) Special Investigator Eleza Jackson was assigned to obtain all medical and police records pertaining to R1. Substantiated Continued from 9099 During today’s visit at approximately 9:45 a.m., LPAs conducted physical plant, interviewed residents, and staff, as well as reviewed and obtained additional pertinent documents relevant to the investigation. Medication audit was also conducted today with Hospice Nurse who is associated with Sweet Touch Hospice and Silver Years Healthcare, approximately between 1 p.m. – 2 p.m. Also, during the visit LPAs reviewed all medical and police records obtained. Following is a summary of the investigation: Allegation 1) Lack of supervision resulting in resident eloping from facility. It was reported that due to lack of supervision R1 eloped from the facility, it was further alleged that R1 eloped multiple times. Information gathered during the investigation reflected that R1 was admitted to the facility on 12/19/2022. During the initial 10-day complaint visit on 02/02/2023, LPA conducted interview with Staff 1 (S1), who revealed R1 did in fact elope from the facility several times. S1 further explained that each time R1 eloped, S1 was servicing another resident. S1 would then contact the family member of R1 to locate R1 via GPS tracking on their phone. During a visit on a separate investigation on 02/07/2023, it was discovered that R1 had eloped again on 02/06/2023 and was struck by a moving vehicle. R1 was admitted to Northridge Hospital and did not return to the facility. Medical records obtained and reviewed revealed R1 sustained multiple rib fractures and hematoma to the right side of the forehead. Based on information obtained during the investigation, the department has sufficient evidence to determine R1 eloped from the facility multiple times due to lack of supervision and as a result sustained serious injury. Therefore, the allegation that lack of supervision resulted in R1 eloping from the facility is deemed SUBSTANTIATED at this time. Allegation 2) Staff not properly managing resident's medication: It was reported that staff are not properly managing resident’s medication. It was reported that S1 did not have knowledge of the medication prescribed to R1 and requested the family to refill a medication not prescribed to R1. Interviews conducted and records reviewed during the initial visit on 02/02/2023, revealed that R1’s responsible party was requested by S1 to order more Lexapro for R1. Review of R1’s Centrally Stored Medication and Destruction Record (CSMDR) revealed Lexapro is not listed on R1’s list of medications. Continued from 9099-C The responsible party corrected S1 and stated that R1 is not prescribed Lexapro. Interviews, medication audit with Hospice nurse and file review conducted on 06/21/23 between 9:45 a.m. – 3 p.m., revealed five (5) out of five (5) resident medications reviewed were observed to be in bubble packs, however LPAs observed the medications were punched out in what appeared to be a random order and was not following any cycle of medications. There were no CSMDR on site to review. LPA’s interview with Staff 2 (S2) regarding medication did not reflect that S2 was properly trained to administer medication to residents in care. Based on information obtained during the investigation, the department has sufficient evidence to determine that staff are not administering medication properly. Therefore, the allegation that staff are not properly managing resident’s medication is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today due to the injury of R1. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). The following deficiencies were observed (See LIC 9099-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. Exit interview conducted. A copy of the report and appeal rights were providedthe state’s words, verbatim · CDSS document, Jun 21, 2023 · control 29-AS-20230131164509

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 22, 2023

Basic services: 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 was not met as evidenced by: Based on interviews and records review the lack of care and supervision resulted in R1 eloping from the facility on multiple occasions and sustaining serious injuries. This poses as an immediate health and safety risk for the residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee has since hired new and additional caregivers. Licensee also agreed to submit a Statement of Understanding demonstrating full understanding of the regulation cited and send to LPA via email by EOD 06/22/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 30, 2023

87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records reviewed there were no centrally stored medication records to review and bubble packs for (5) out of the (5) residents appeared to not be dispensed properly. This poses a potential health and safety rise for the residents in carethe state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee has agreed to hold a staff meeting to conduct training and review regulation. Licensee agreed to submit sign-in sheet of those who attend and submit a statement of understanding demonstrating full understanding of the regulation cited and send to LPA via email by 06/30/2023.

Allegation investigated: Facility staff falsified records

Licensing Program Analysts (LPA)s Brian Balisi and Zabel Chochian conducted a subsequent complaint visit to investigate the allegation listed above. Upon arrival, LPAs met with staff Zhyparkul Mursamambetova and explained the reason for the visit. Administrator Sarkis Dovlatyan arrived shortly after. On 4/13/2023, the initial complaint visit was conducted by LPA Balisi between approximately 9 a.m. - 3:30 p.m. During the visit, LPA conducted physical plant, interviewed staff, residents, responsible parties, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. LPA Balisi attempted to obtain Sweet Touch Hospice records on 04/12/2023 and 06/20/2023 but, was not successful. Today, at approximately 9:45 a.m., LPAs conducted a tour of the physical plant, interviewed staff, as well as reviewed and obtained additional pertinent documents relevant to the investigation. It was reported that facility staff falsified records as it was alleged that hospice services were being provided to Resident 1 (R1) from 12/19/2022 to 03/18/2023. Substantiated Continued from 9099 Information gathered during the investigation reflected that R1 was admitted to the facility on 12/19/2022, however the family responsible for R1 denies admitting R1 into hospice services. The family member also stated that neither facility staff nor any health care professionals ever discussed with the family about admitting R1 into any hospice services. Per hospital records and interview with the family, on 02/06/2023, R1 eloped from the facility and was later admitted into a local hospital (under investigation on Complaint Control #29-AS-20230131164509) and did not return to the facility. According to the family they obtained R1's belongings from the facility on 02/09/2023. Information obtained from records review and interviews conducted with responsible parties of other residents in care revealed that Resident 2 (R2) and Resident 3 (R3) were also receiving services from Sweet Touch Hospice. R3s responsible party stated R3s records indicated that R3 was receiving services from Sweet Touch Hospice from July 2021 to March 2023, but R3s responsible party also denied signing R3 up for any service with Sweet Touch Hospice. R2s responsible party stated they did in fact admit R2 into services with Sweet Touch Hospice. Interviews conducted with Administrator revealed that they have been business partners for approximately 10 years with Anna Hakobyan who has been identified as an individual associated with Sweet Touch Hospice. Administrator indicated they receive payments from all residents and denied any knowledge of any residents paying or being in contact with Anna. Administrator continued to state families may be in contact with Anna for hospice or home health services. Based on information obtained during the investigation, the department has sufficient evidence to determine that R1 received hospice services that they had not agreed to receive. Therefore, the above allegation is deemed SUBSTANTIATED at this time. The following deficiencies were observed (See LIC 9099-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. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 21, 2023 · control 29-AS-20230411112334

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(a) · Plan of correction due date: Jun 30, 2023

The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill... in the facility when all the following conditions are met: This requirement was not met as evidenced by: Based on information gathered during the investigation the licensee did not comply with the section cited as R1 and R3 were admitted into hospice services they did not agree to. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee agreed to submit a Statement of Understanding demonstrating full understanding of the regulation cited and send to LPA via email by EOD 06/30/2023.

Allegation investigated: Facility did not issue a refund

Licensing Program Analysts (LPA)'s Brian Balisi and Zabel Chochian conducted a subsequent complaint visit to investigate the allegation listed above. Upon arrival LPA’s met with staff Zhyparkul Mursamambetova and explained the reason for the visit. Administrator Sarkis Dovlatyan arrived shortly after. On 02/07/2023, the initial complaint visit was conducted by LPA Balisi between approximately 9:30am - 12pm. During the visit. LPA conducted physical plant, interviewed staff, responsible parties as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. Today at approximately 9:45am, LPAs conducted physical plant, interviewed residents, and staff as well as reviewed and obtained additional pertinent documents relevant to the investigation. It was reported that facility did not issue a refund as it was alleged that the responsible party for Resident 1 (R1) was due a refund since November 2022. Substantiated Continued from 9099 Interviews conducted and records review revealed that R1 was admitted into this facility in 11/22/2022, but relocated out of the facility (7) days later. Resident records for R1 were not available onsite for LPAs to review. The responsible party stated they were charged $2,300 for thirty (30) days , but R1 resided in the facility for only (7) days. Records review further revealed communication via text messages between the responsible party and facility staff, confirming a refund was owed and due to be sent to the responsible party. The responsible party stated no refund has been issued at this time. Based on information obtained during the investigation, the department has sufficient evidence to determine that R1's responsible party has not received a refund. Therefore, the above allegation that facility did not issue a refund is deemed SUBSTANTIATED at this time. The following deficiencies were observed (See LIC 9099-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. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 21, 2023 · control 29-AS-20230202134526

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.651(g) · Plan of correction due date: Jun 30, 2023

If the applicant decides not to enter the facility prior to the facility’s completion of a preadmission appraisal... entitled to a refund of 100 percent of the preadmission fee. This requirement was not met as evidenced by: Based on information gathered during the investigation the licensee did not comply with the section cited as per R1’s responsible party they have not received a refund as of 06/21/2023. This poses as a potential health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee agreed to provide proof of refund and submit a Statement of Understanding demonstrating full understanding of the regulation cited and send to LPA via email by EOD 06/30/2023.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Brian Balisi and Zabel Chochian conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20230411112334). LPAs met with Sarkis Dovlatyan. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. During the complaint investigation, interviews conducted reflected that all matters related to the operation of the facility such as payment for services, hospice care, and any matters related to the well-being of the residents are communicated with an individual named Anna Hakobyan. Interview with Administrator revealed that they have been business partners for approximately 10 years, but Administrator indicated they receive payments from all residents and denied any knowledge of any residents paying or being in contact with Anna. Administrator continued to state families may be in contact with Anna for hospice or home health services. LPAs discussed with administrator that Anna Hakobyan was excluded by the Department and should not have any involvement with the day-to-day operations of the facility. A copy of the accusation was also provided to the administrator during today’s visit. In addition, during today’s visit, LPAs conducted a physical plant tour at approximately 9:45am and observed five (5) out of five (5) residents with full bed rails. Resident records review at approximately 1pm – 2pm, revealed that the facility does not maintain accurate resident records. Administrator and LPA reviewed five (5) resident hospice records and did not find any order for the full rails. Five (5) out of five (5) resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. No staff records on site to review. During the visit Administrator revealed to LPAs their Administrators certificate is expired. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.the state’s words, verbatim · CDSS document, Jun 21, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Jun 22, 2023

Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement was not met as evidenced by: Based on observervation the LIcensee did not comply with this regulation as LPAs observed full bed rails in (5) out of (6) clients in care. This poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee agreed to remove all full bed rails or submit proof of hosice care plans to LPA via email by EOD 06/22/2023.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.58 · Plan of correction due date: Jun 22, 2023

a) The department may prohibit any person from being a licensee...,any employee, prospective employee, or person who is not a client and who has done any of the following: This requriement was not met as evidenced by: Based on interviews conducted interviews conducted reflected that all matters related to the operation of the facility such as payment for services, hospice care, and any matters related to the well-being of the residents are communicated with an individual named Anna Hakobyanthe state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee has been informed and provided a copy of the Decision and order and understans that the individual cannot have any form contact with clients at any facility licensed by the department. Licensee will also submit a statment of understanding of section cited to LPA by EOD 06/22/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Jun 30, 2023

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidenced by: Based on interviews and records review, LPAs did not observe any staff records on site to review. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee agreed to maintain full staff files in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 06/30/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b)(F) · Plan of correction due date: Jun 30, 2023

87506(b)(F) Each resident’s record shall contain at least the following information...(17) documents and information...(F)Section 87505, Documentation and support. This requirement was not met as evidenced by: Based on records review Five (5) out of five (5) resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee agreed to maintain full resident files in the facility. LIcensee also agreed to submit proof of understanding and submit to LPA via email by EOD 06/30/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Jun 30, 2023

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement was not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited as LPAs reviewed revealed five (5) resident hospice records and did not find any order for the full rails. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee agreed to maintain full hospice care plan in the facility. LIcensee also agreed to submit proof of understanding and submit to LPA via email by EOD 06/30/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jun 30, 2023

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by: Based on interviews conducted Licensee did not comply with the section cited as Licensee revealed to LPAs their Adminitrators certificate is expired. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2023

Plan of correction: Licensee agreed to submit request for change of Administrator along with the supporting documents to LPA by EOD 06/30/2023.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Other visit at the facility. At approximately 9am, LPA was greeted by staff and explained the reason for the visit. Upon entering facility LPA was then met by Administrator Sarkis Dovlatyan. At approximately 9:05am, LPA toured facility with Administrator and spoke with Admin regarding recent staffing concerns. LPA also spoke with the (2) staff on duty. LPA reminded Administrator to submit paperwork for back up Administrator and provide updated LIC 500 to LPA by end of day. Administrator stated they will be overseeing facility at this time and will ensure there will be sufficient staffing until new management takes over. Administrator also indicated they have been in constant communication with new management. No immediate health and safety concerns were observed during today's inspection. Exit interview conducted report issued and sent via email.the state’s words, verbatim · CDSS document, Jan 3, 2023

Allegation investigated: Facility does not have a desginated subsititute administrator.

Licensing Program Analyst, Christine Yee, conducted a subsequent complaint visit to conduct further investigations and to deliver the findings of the above allegation. LPA Yee met with Villalyn Agustin, staff and the reason for today's visit was explained. On 5/23/22, LPA Brian Balisi conducted an intial complaint visit. During the initial complaint visit, LPA Balisi interviewed staff, residents, reviewed and obtained copies of pertinent documents relevant to the investigation and determined that further investigation was required. On today's visit, LPA Yee conducted face to face interviews with Staff #1, Staff #2, continued on LIC9099 C Substantiated Sarkis Dovlatyan, former Licensee, Residents and reviewed facility documents. Per information received during the investigation, the last known Administrator was Dinah Pasco and she resigned on April 10, 2022, per the resignation letter observed in her facility file. Ms. Pasco was also disassociated from the facility on 5/1/22 per Department records. Department records show that administrator documents were submitted for Katchik Danielian as designated backup administrator on June 1, 2022. However, the documents were incomplete and the appropriate criminal record clearances were not obtained to qualify Katchik Danielian as a backup administrator. Per Staff, they report to a Anna Hakobyan and John Santos via telephone if there are any issues at the facility issues. They are not present at the facility. Per interview conducted with Sarkis Dovlatyan, former Licensee who resides next door to the facility, he is always around the facility but he is the property owner and has had no involvement with the daily operations of the facility since 8/1/2022 and does not provide any administrative oversight other than maintenance services. Based on information obtained during the investigation and observed on today's visit, the facility does not have any qualified administrator or backup administrator on the premises to provide administrative oversight. Therefore, the above allegation is SUBSTANTIATED. Deficiencies are being cited under Title 22 Division 6 Chapter 8 of the California Code of Regulations. Exit interview was conducted with Villalyn Agustin, Appeals Rights were discussed and a copy of the report was given.the state’s words, verbatim · CDSS document, Dec 28, 2022 · control 29-AS-20220516152826

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Jan 6, 2023

87405(a) Administrator Qualifications and duties: (a)All facilities shall have a qualified and currently certified administrator....When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement was not met and poses an immediate danger to the residents in carethe state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: The licensee will submit a plan of action as to how the facility will come into complance by 12/29/22 and submit Administrator documents to designate a qualified person as facility administrator and another person as backup administrator by 1/6/23

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Christine Yee, conducted a case management visit as a result of the deficiencies observed during a visit to the facility today. LPA Yee was allowed entry into the home by Alejandra Mendoza, Staff. The visit was conducted with Villalyn Agustin, Staff. The reason for today's visit was explained. During the visit, LPA Yee observed the following deficiences : the medication cabinet was left unlocked and unattended. Cabinet was locked when it was pointed out to staff by LPA Yee Osana Keshishian, staff is at the facility 2 times a week to complete paperwork without obtaining a criminal record clearance and being associated to the facility Khatchik Danielian, staff appointed as a designated backup administrator has not requested a criminal record clearance or exemption and is not associated to the facility. He has been observed at the facility. Deficiencies are being cited under California Code of Regulations, Title 22, Chapter 6, Division 8. CIVIL PENALTIES are being assessed.the state’s words, verbatim · CDSS document, Dec 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 28, 2022

87465(h)(2)INCIDENTIAL MEDICAL AND DENTAL CARE: the following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met and poses a danger to the residents in care. The medication cabinet was observed left unlocked and unattendedthe state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: The licensee shall ensure that all medications centrallly stored are kept in a locked cabinet and inaccessible to residents at all times. ****corrected at time of visit

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Dec 29, 2022

CRIMINAL RECORD CLEARANCES: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or Osana Keshishian, staff is at the facility to complete paperwork 2x a week withiout evidence of a criminal record clearance. This poses a danger to the residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: The Licensee will ensure that all staff have obtained a criminal record clearance and associated to the facility prior being present at the facility. Submit evidence that Osana Keshishian has obtained the appropriate clearance by 12/29/22 and prior to being present at the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(3) · Plan of correction due date: Dec 29, 2022

CRIMINAL RECORD CLEARANCES: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. Khatchik Danielian has not requested an exemption to be present at the facility. This poses a danger to the residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: The Licensee shall ensure that all individuals are cleared and have obtained an exemption prior to being present a the facility. Provide evidence that Khatchik Danielian has obtained the appropriate criminal record clearances prior to being present at the facility by 12/29/22

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with caregiver Wynn and explained the reason for the visit. LPA spoke with Administrator Sarkis over the phone, who stated it was okay for Wynn to sign for the report. A tour of the physical plant was conducted with Wynn approximately between 10:30am - 12:30pm LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: The facility has three (3) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bathroom is designated for staff use. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings in the living area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer to the right of the dishwasher. Medication is stored in a locked cabinet above the dishwasher. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Continued from 809 Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom Residents have sufficient amounts of supplies for personal hygiene stored in the designated staff bathroom. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit in all bathrooms during visit. Laundry area was located in the staff bathroom as well. Cleaning supplies were observed stored in locked cabinets inaccessible to residents in care. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. At 11am, LPA observed (3) residents watching television in the living room area. There is a entry closet located by the front door. LPA observed non-perishables, emergency supplies and PPE stored here at this time. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use in the front and rear of the facility. There are no bodies of water on the premises. There was an Adult Dwelling unit located in the rear of the facility. LPA observed unit to be empty at this time and inaccessible to residents.At 12pm, LPA observed residents having lunch at dining table. The LPA spoke with Wynn regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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 bedroom #1 as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Exit interview conducted, report issued and sent via email.the state’s words, verbatim · CDSS document, Jul 12, 2022

Allegation investigated: Staff moved resident to another home without consent Staff is withholding resident's mail

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint investigation for the above allegations. LPA met wtih Assistant Administrator Dinah Pasco and explained the reason for the visit. Regarding the above allegation, it was alleged facility staff moved resident to another home without consent and Staff is withholding resident's mail. Based on the interviews conducted and records reviewed, LPAs confirmed R1 had never resided at this facility. Based off the information obtained, the allegation is deemed unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and a copy of this report was reviewed and issued. Unfoundedthe state’s words, verbatim · CDSS document, Feb 1, 2022 · control 29-AS-20220125144508

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Zabel Chochian initiated a Case Management visit today. Upon arrival LPA rang the door bell a couple of times and no one answered. LPA called facility and spoke with staff Wynn Apao. Staff stated to LPA that they did not hear the door bell ring. LPA asked staff to test the door bell while LPA waited inside. Facility door bell ring could not be heard in the facility. Staff contacted Licensee and the electronic door bell system was reset and functioning upon reset of the system during LPA's visit. Reason for visit as explained to Staff. Staff contacted back-up administrator Dinah Pasco. LPA as informed that facility administrator Sarkis D. is not available at this time. LPA explained reason for the visit. On 12/05/21, this facility submitted a Death Report for resident #1 (R1) which noted a stage 3 pressure injury. Follow Information was gathered from Licensee/Administrator Sarkis D. and backup Administrator Dinah P. R1 was discharged from Kaiser Permanente - Downey and admitted to this facility on 11/26/2021 with stage 3 pressure injury on buttocks area. According to Ms. Pasco R1 was admitted to the facility with stage 4 cancer and pressure injury. Ms. Pasco stated that she was not aware of the staging of the wound until after R1 was admitted. Ms. Pasco also stated that they were in the process of getting the resident on hospice. However, on 12/1/2021 she discussed with R1's family and decided to transfer resident back to the hospital for further evaluation of the wound. Resident 1 passed way on 12/3/2021 at Kaiser Permanente - Woodland Hills. Ms. Pasco stated that she is waiting for a death summary from Kaiser and will submit to case LPA soon as she receives the death summary. During today's visit, a file review was conducted at 2:30 p.m. Physician report dated 10/21/2021, indicated R1 had a Stage 3 pressure injury. Ms. Pasco admit that its their fault for not obtaining record of the wound staging prior to admitting R1. Based on the investigation, there is sufficient evidence to support that R1 was admitted to and retained in this facility for several days with a prohibited health condition. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted. A copy of the report issued.the state’s words, verbatim · CDSS document, Dec 16, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Dec 17, 2021

87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition ... shall not be admitted or retained in a residential care facility for the elderly: Stage 3 or 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as they admitted and retained R1 in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2021

Plan of correction: The Administrators agree to do the following: Review Regulation 87615 and submit a Statement of Understanding, detailing how the facility will maintain compliance moving forard. Submit statement to CCLD by 12/17/2021.

Allegation investigated: Staff are not wearing masks. Facility is not following COVID-19 screening protocals.

On December 6, 2021, at 11:05 a.m., Licensing Program Analysts (LPA's), Martha Guzman Chavez and KaSandra Lopez conducted an unannounced complaint investigation for the above allegations. LPA's were greeted at the door by staff, Wynn. The Administrator, Dinah Pasco, arrived at the facility at 12:04 p.m., and was explained the reason for the visit. Entrance interview conducted. It was alleged that staff are not wearing masks. It was reported by the reporting party that while conducting an unannounced visit, they observed that the caregivers were not wearing masks. The LPA’s interviewed the Administrator and two staff between 11:10 a.m. and 1:15 p.m. and reviewed facility files at 12:30 p.m. Upon arrival to the facility, LPA’s observed the staff wearing masks inside the facility. However, interviews with staff revealed that while an outside agency came to visit, one of the staff was not wearing the mask properly. The caregiver admitted to having the mask on the chin. Interview with another staff further revealed that on a different occasion, while family members came to the facility, staff were also not wearing their masks properly. Based on interviews, the allegation of “staff are not wearing masks” is deemed Substantiated at this time. ...Continued on LIC 9099C... Substantiated ...Continued from LIC 9099... It was further alleged that facility is not following COVID-19 screening protocols. Upon entering the facility, the LPA’s were screened at the door and temperatures were taken by Staff. Although the LPA’s were screened, the LPA’s were not asked Covid-19 related screening questions. Furthermore, the LPA’s were not asked to sign in. Additionally, LPA’s observed a Home Health nurse coming into the facility at 11:00 a.m. However, upon record review, the LPA’s observed that the Home Health nurse had not signed into the visitor’s log showing that they had been screened for COVID-19. During staff interviews, staff reported that they were busy and had forgotten to have nurse sign in. Based on interviews and record review, the allegation of “facility is not following COVID-19 screening protocols” is deemed Substantiated at this time. Citations Issued. See LIC 9099D. Appeal Rights discussed. Copy of the report emailed to Administrator.the state’s words, verbatim · CDSS document, Dec 6, 2021 · control 29-AS-20211201090238

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 7, 2021

87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based observations and interviews, the Licensee did not ensure the personal rights of persons in care to live in a safe, healthy, and comfortable home as staff did not wear face coverings at all times while inside the facility and do not follow COVID-19 infection screening protocol, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2021

Plan of correction: The Administrator will advise the staff on wearing masks at all times inside the faciltiy and conduct a training on CA Dept of Public Health Guidance for the use of face coverings issued/updated on 11/16/2020 and COVID-19 screening protocols and submit proof to LPA by 12/17/2021.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) KaSandra Lopez and Martha Guzman-Chavez conducted an unannounced Case Management - Deficiencies report due to deficiencies observed during the complaint investigation of complaint control #29-AS-20211201090238 beginning at 11:05 AM. At 11:33 AM Dinah Pasco who was identified as the Administrator by the caregiver, was contacted and the LPAs spoke with her and advised her of the reason for today's inspection. The LPAs met with Dinah Pasco at 12:05 PM at the facility. At 12:32 PM the LPAs spoke with Licensee Representative Sarkis Dovlatyan on the telephone and explained to him the reason for the inspection also. Licensee Representative confirmed Dinah Pasco was the new Administrator and stated the paper for the change had been submitted. During the complaint investigation, it was observed that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were not associated to the facility. Interviews with S1, S2, and S3 revealed each staff have worked at the facility for more than five days. Therefore, civil penalties will be assessed in the amount of $500 ($100 a day x 5 days) each for S1, S2, and S3. Resident record review was conducted for three of the five residents beginning at 1:52 PM. Record review revealed, Resident #1 (R1) did not have a completed facility file, including signed admission agreement, medical assessment, emergency identification, signed personal rights, or appraisal on file. The only records R1 had in file was hospital records. Record review also revealed the following, Resident #2 (R2) was missing the rate for basic services on their signed admission and did not have a medical assessment on file, and Resident #3 (R3) did not have a signed admission agreement on file. At 5:57 PM, Licensee Representative Sarkis Dovlatyan was contacted via telephone to go over the report and to discuss the following. On approximately 04/09/2015, Corporation Age Well Assisted Living, Inc. listed Sarkis Dovlatyan as 100% owner of the corporation. Report continued on LIC 809-C. California Secretary of State records reflect on 09/12/2021 the Chief Executive Officer of the corporation was listed as Oganes Duymalyan, although California Secretary of State records now reflect Sarkis Dovlatyan as the Chief Executive Director again as of 11/17/2021. The LPAs discussed with Mr. Dovlatyan the change of the Chief Executive Officer for the corporation, and the change back to Mr. Dovlatyan. Mr. Dovlatyan understands that a transfer of the majority of stock constitutes a majority change in ownership which would be considered a forfeiture of license. Mr. Dovlatyan understands by doing so, the facility would be considered operating unlicensed. Mr. Dovlatyan stated he was not aware of the change of Chief Executive Director until the SBA advised him of this and stated he did not know who Oganes Duymalyan was. Mr. Dovylatyan stated a new applicant has applied for licensure at this location, but understands he is still responsible for the operation of the facility until the new license is approved and that a license cannot be sold or transferred to another individual or entity. The LPAs also advised Mr. Dovlatyan that in the matter of Anna Hakobyan, a Decision and Order that became effective September 30, 2021 excludes Anna Hakobyan from any care facility licensed by the Department pursuant to Health and Safety Code 1569.58. Excluding Anna Hakobyan from being a licensee, owning a beneficial ownership interest of 10% or more in a licensed facility, or being an administrator, officer, director, member, or manager of a licensee or entity controlling a licensee, and, further, from all care facilities licensed by the Department, for the remainder of her life, unless she successfully petition for reinstatement or reduction of penalty. A copy of the Accusation dated 10/31/2018, and the Decision and Order were given to the parents of Mr. Dovlayton who live in the back house on the property per his request. Exit interview and report reviewed with Mr. Dovlatyan. Administrator Dinah Pasco signed the report. A copy of the report, appeal rights, Accusation, and Decision and Order will be emailed to Mr. Dovlatyan.the state’s words, verbatim · CDSS document, Dec 6, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 6, 2021

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant....(b) shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as three staff (S1, S2, and S3) criminal record clearances were not transferred to the facility which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2021

Plan of correction: The licensee shall update in Guardian or submit the LIC 9182, LIC 508 and a copy of the photo ID to the Woodland Hills North Regional office for S1, S2, and S3. Civil penalties shall continue to accrue until the plan of correction is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(a)(g)(A) · Plan of correction due date: Dec 13, 2021

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement,...(g) Admission agreements shall specify the following:(A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above as three residents (R1, R2, R3) out of three files reviewed, revealed R1 and R3 did not have a signed admission agreement and R2's admission agreement was not complete which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2021

Plan of correction: The Licensee/Administrator shall submit proof R1 and R3 has a completed and signed admission and agreement and R2 has a completed admission agreement with the basic rate listed to CCLD by 12/13/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Dec 20, 2021

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89)... This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above, as two residents (R1 & R2) out of three residents did not have a medical assessment on file which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2021

Plan of correction: The licensee/administrator shall submit proof R1 and R2 have a medical assessment signed by a physician within the last year, to CCLD by 12/20/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Dec 13, 2021

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above, as one resident (R1) out of three residents did not have a completed facility file which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2021

Plan of correction: The licensee/administrator shall submit proof R1 has a completed file, including but not limited to, identification and emergency information, appraisal, signed personal rights form to CCLD by 12/13/2021.