157209266-3-7-2023-24-AS-SPIY-CQ7KZZ-20230323082134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209266
Report Date: 03/07/2023
Date Signed: 03/07/2023 07:01:42 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2023 and conducted by Evaluator Les Xiong

COMPLAINT CONTROL NUMBER: 24-AS-20230302164540

FACILITY NAME:	HEAVENLY CASTLE CARE INC		FACILITY NUMBER:	157209266
ADMINISTRATOR:	NSHANYAN, HASMIK		FACILITY TYPE:	740
ADDRESS:	1651 WHITE ROCK RD		TELEPHONE:	(310) 993-2447
CITY:	FRAZIER PARK	STATE: CA	ZIP CODE:	93225
CAPACITY:	6	CENSUS: 2	DATE:	03/07/2023
		UNANNOUNCED	TIME BEGAN:	03:33 PM
MET WITH:	Hasmik Nshanyan		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

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Residents do not have access to phone service.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. LPA met with Administrator Hasmik Nshanyan and informed her the purpose of the visit.
During the course of this investigation LPA interviewed staff and residents relevant to the complaint investigation. It was determined that the above allegation: Residents do not have access to phone service is UNFOUNDED. The evidence from the investigation indicated, there were cellular telephones available for facility/residents use.This agency has investigated the complaint alleging (Residents do not have access to phone service). We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2023 and conducted by Evaluator Les Xiong

COMPLAINT CONTROL NUMBER: 24-AS-20230302164540

FACILITY NAME:	HEAVENLY CASTLE CARE INC		FACILITY NUMBER:	157209266
ADMINISTRATOR:	NSHANYAN, HASMIK		FACILITY TYPE:	740
ADDRESS:	1651 WHITE ROCK RD		TELEPHONE:	(310) 993-2447
CITY:	FRAZIER PARK	STATE: CA	ZIP CODE:	93225
CAPACITY:	6	CENSUS: 2	DATE:	03/07/2023
		UNANNOUNCED	TIME BEGAN:	03:33 PM
MET WITH:	Hasmik Nshanyan		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

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9

Bodies of water are accessible to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) L. Xiong conducted a complaint investigation visit to the facility.
During the course of this investigation LPA interviewed staff, residents, obtained records relevant to the complaint investigation. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. The evidence from the investigation indicated there is an unfence pond on the premise of the facility about 200-300 feet from the fenced back patio and 500 feet from the front entrance. Based on LPA's observation and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20230302164540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HEAVENLY CASTLE CARE INC	FACILITY NUMBER: 157209266
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/14/2023 Section Cited CCR 87705(e)	1 2 3 4 5 6 7	87705 (e) Care of Persons with Dementia: Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. LPA observed an unfence pond on the premise of the facility.	1 2 3 4 5 6 7	Per Administrator, will contact contractor for appointment by the POC date and have the pond fenced ASAP/when weather permits.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC9099 (FAS) - (06/04)

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