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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209266
Report Date: 03/07/2024
Date Signed: 03/07/2024 02:52:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/08/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20231208154942
FACILITY NAME:HEAVENLY CASTLE CARE INCFACILITY NUMBER:
157209266
ADMINISTRATOR:NSHANYAN, HASMIKFACILITY TYPE:
740
ADDRESS:1651 WHITE ROCK RDTELEPHONE:
(310) 993-2447
CITY:FRAZIER PARKSTATE: CAZIP CODE:
93225
CAPACITY:6CENSUS: 5DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Administrator Hasmik NshanyanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff is unable to communicate effectively with the residents
Staff charged a resident for services not received
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda contacted the facility to commence a complaint investigation. LPA's identified themselves and explained the purpose of the visit to staff. LPA Doucette contacted Administrator Hasmik "Jasmine" Nshanyan via telephone who responded to assist with the visit.

During the course of the visit LPA's asked for resident files. Staff were unable to provide the files due to a language barrier. LPA's were able to obtain the files once the Administrator arrived. Based on observation and interviews staff are unable to communicate with residents at the facility.

Based on records review and interviews, facility had receipts for a U- Haul to move R1's belongings out of storage, which does not match the receipt provided to the resident. Based on record review and interviews, staff charged a resident for services. Facility does not have a signed agreement from R1 for the facility to provide the service.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
12/08/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20231208154942

FACILITY NAME:HEAVENLY CASTLE CARE INCFACILITY NUMBER:
157209266
ADMINISTRATOR:NSHANYAN, HASMIKFACILITY TYPE:
740
ADDRESS:1651 WHITE ROCK RDTELEPHONE:
(310) 993-2447
CITY:FRAZIER PARKSTATE: CAZIP CODE:
93225
CAPACITY:6CENSUS: 5DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Administrator Hasmik NshanyanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
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9
Staff neglect resulted in a resident sustaining multiple pressure injuries
Staff mishandles a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda contacted the facility to commence a complaint investigation. LPA's identified themselves and explained the purpose of the visit to staff. LPA Doucette contacted Administrator Hasmik "Jasmine" Nshanyan via telephone who responded to assist with the visit.

Based on interviews with Hospice and records review, it is unknown if Staff neglected a resident which resulted in a resident sustaining multiple pressure injuries. Resident was moved to a higher level of care.

Based on interviews, it is uknown if staff mishandled a resident while in care. LPA was unable to determine if this allegation occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 5
Control Number 24-AS-20231208154942
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
VISIT DATE: 03/07/2024
NARRATIVE
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The Department has investigated the above allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.


An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20231208154942
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
VISIT DATE: 03/07/2024
NARRATIVE
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Based on interviews and records review the preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, deficiencies are being cited on the attached 9099-D.

An exit interview was conducted and a copy of this report along with appeal rights and plans of correction were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20231208154942
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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
87411(d)(3)
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Personnel Requirements - General
87411 (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
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Plan of Correction POC Licensee agrees to submit a plan on how caregivers will be able to communicate with residents by POC due date
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(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by Licensee did not ensure staff is able to communicate with LPA or residents which poses a potential health safety and or personal rights risk to residents in care.
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Type B
03/15/2024
Section Cited
CCR
87507(g)(3)(B)1.
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87507 Admission Agreements (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including 1. A comprehensive description of and
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Plan of Correction Licensee agrees to submit a written statement on how this regulation will be met in the future by POC due date 03/15/24.
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the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. This requirement was not met as evidenced by: Licensee provided a service without completed receipts or a signed agreement between Licensee and resident which poses a potential health safety and or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5