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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850058
Report Date: 11/09/2021
Date Signed: 11/10/2021 07:46:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211103161924
FACILITY NAME:IMPRESSIVE CARE, INC.FACILITY NUMBER:
195850058
ADMINISTRATOR:TAGARYAN, ARMINE ADRINEFACILITY TYPE:
740
ADDRESS:13302 ARMINTA STREETTELEPHONE:
(818) 517-6594
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 1DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariam BaghgogyanTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility is not following resident's medical orders.
INVESTIGATION FINDINGS:
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On 11/09/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day complaint investigation visit regarding the above allegations. LPA Urena met with the Staff at 9:00 am, and explained the reason of the visit. Administrator was not available during today’s visit.

During today’s visit, at 9:15 am, LPA Urena, and the staff conducted a tour of the facility, inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At 9:20 am, the LPA and staff toured three bedrooms. Bedrooms were found to be in clean condition, sufficient lighting, and furnished with appropriate furniture and linens. The LPA did not detect any malodors. The LPA and staff toured the bathroom, and found it to be in clean condition with soap and paper towels available for residents.
LPA Urena obtained and reviewed records from 11:15 am to 12:00pm, conducted interviews from 12:15pm to 12:30pm. Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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
Control Number 29-AS-20211103161924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IMPRESSIVE CARE, INC.
FACILITY NUMBER: 195850058
VISIT DATE: 11/09/2021
NARRATIVE
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Regarding the allegation: Facility is not following resident's medical orders.

The complainant alleged that the staff is not giving the resident the prescribed routine medication Norco to resident #1(R1). LPA Urena conducted a medication audit together with the staff # 1(S1). To investigate, the LPA reviewed R1’s Medication Administration Log, inspected the Norco medication packets, and the physician’s orders. The LPA found that the medication packets contained the pills inside the bubbles. The LPA found two sets: each set consisted of three packets. Each set had one packet labeled AM, one packet labeled AFTERNOON, and one packet labeled EVENING. One set (three packets) was dated 10/15/2021 and the second set (three packets) dated 10/27/2021. The EVENING packet dated 10/27/2021 had the bubbles numbered # 11, 12, 13, & 14 empty. In addition, the LPA reviewed the medication administration log and found only one entry in the log, dated 10/28/2021-9:00pm. Per the physician's order, the medication Norco is to be administered "by mouth every 8 hours routinely".

Based on the LPA’s observations, interviews, and records reviewed, the above allegation(s) is found to be SUBSTANTIATED at this time.



Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (please refer to LIC 9099-D).

Administrator was on vacation and not available for the exit interview/ Exit interview conducted with Caregiver Mariam Baghgogyan/ Citations were issued/ Appeal Rights Provided / A copy of the repot was emailed to the Administrator for their signature and to be returned signed to the LPA by Monday, November 15, 2021.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20211103161924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IMPRESSIVE CARE, INC.
FACILITY NUMBER: 195850058
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care: (a)A plan for incidental medical... care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...
This requirement is not met as evidenced by:

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Administrator will provide documentation of staff training regarding regulation 87465 (a)(5) to CCL by 11/19/2021.
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Based on LPA's observation, the licensee did not comply with the section cited above, as medications were not administered according to physician’s orders based on administration log review and medication audit, which poses a potential health and safety risk to persons 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211103161924

FACILITY NAME:IMPRESSIVE CARE, INC.FACILITY NUMBER:
195850058
ADMINISTRATOR:TAGARYAN, ARMINE ADRINEFACILITY TYPE:
740
ADDRESS:13302 ARMINTA STREETTELEPHONE:
(818) 517-6594
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 1DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariam BaghgoyanTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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The residents' basic needs are not met.
INVESTIGATION FINDINGS:
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On 11/09/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day complaint investigation visit regarding the above allegations. LPA Urena met with the Staff at 9:00 am, and explained the reason of the visit. Administrator was not available during today’s visit.

During today’s visit, at 9:15 am, LPA Urena, and the staff conducted a tour of the facility, inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At 9:20 am, the LPA and staff toured three bedrooms. Bedrooms were found to be in clean condition, sufficient lighting, and furnished with appropriate furniture and linens. The LPA did not detect any malodors. The LPA and staff toured the bathroom, and found it to be in clean condition with soap and paper towels available for residents.

LPA Urena obtained and reviewed records from 11:15 am to 12:00pm, conducted interviews from 12:15pm to 12:30pm. Continues on LIC 9099 C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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 29-AS-20211103161924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IMPRESSIVE CARE, INC.
FACILITY NUMBER: 195850058
VISIT DATE: 11/09/2021
NARRATIVE
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It is alleged that facility staff is not changing residents often enough, nor attending to their basic needs. LPA Urena conducted interviews with staff #1 (S1). LPA Urena asked S1 about the personal care and diaper change schedule for residents. S1 stated that the residents are changed throughout the day, and added that if more times are needed, then they are changed. In regard to personal care, S1 stated that if residents receive hospice services, then hospice gives shower and provides personal care, if not, S1 gives bath to residents two times a week. S1 added that S1 brushes residents’ teeth every morning. During today’s visit, LPA Urena attempted to interview residents #2 (R2), however, R2 was unable to answer questions asked by the LPA.

Based on the information gathered for the allegation, there were no other witnesses to the event, nor did any other resident experience that issue. Therefore, although the allegation may have happened or is valid, there is insufficient evidence to confirm that a residents’ basic needs are not met. Therefore, the allegation is deemed as UNSUBSTANTIATED at this time.

Administrator was on vacation and not available for the exit interview/ Exit interview conducted with Caregiver Mariam Baghgogyan/ No citations were issued/ A copy of the Repot was emailed to the Administrator for their signature and to be returned signed to the LPA by Monday, November 15, 2021.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5