195850075-8-23-2021-29-AS-DPEA-CQ8V5V-20230324160831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850075
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:53:17 PM

Unsubstantiated

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
01/20/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210120163102

FACILITY NAME:	A-1 BOARDING CARE		FACILITY NUMBER:	195850075
ADMINISTRATOR:	CHARCHYAN, KARINE		FACILITY TYPE:	740
ADDRESS:	6511 BONNER AVE.		TELEPHONE:	(818) 691-3146
CITY:	N. HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 4	DATE:	08/23/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Hovhannes Ispiryan - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Residents file is missing emergency documents
Staff threatened to evict resident
Staff did not safeguard residents personal belongings
Staff did not prevent inappropriate room accommodations

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit for the above allegation. LPA met with Hovhannes Ispiryan and explained the reason for the visit.

During the investigation, LPA conducted a physical plant tour virtually on 01/25/2021 as well as interviewed Administrator. On 6/10/2021, LPA conducted interviews with facility staff, and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation.

It was alleged that Residents file is missing emergency documents, LPA records review of all residents in care as well as Resident 1 (R1), revealed that each resident folder appeared to have all the appropriate documents at this time. Based on information gathered during this and previous visits, the department does not have sufficient evidence to determine that residents file is missing emergency documents at this time. Therefore, the above allegation is UNSUBSTANTIATED at this time.
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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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Control Number 29-AS-20210120163102

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: A-1 BOARDING CARE	FACILITY NUMBER: 195850075
	VISIT DATE: 08/23/2021

NARRATIVE

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Continued from 9099

It was alleged that Staff threatened to evict resident, LPA interview with residents in care revealed that all have not witnessed staff ever threatened to evict another resident. Each resident also stated they have not been threatened with eviction as well. LPA records review revealed that an eviction notices was never issued to R1. Based on information gathered during this and previous visit, the department does not have sufficient evidence to determine that staff threatened to evict resident. Therefore , the above allegation is UNSUBSTANTIATED at this time.

It was alleged that staff did not safeguard resident’s personal belongings, LPA interview with residents in care revealed that each resident did not express any immediate concerns that staff are not safeguarding their personal belongings. Interviews with residents also revealed that most have never had any of their personal items missing. LPA records review revealed that each resident has completed their client/resident Personal Property and Valuables form. Based on information gathered during this and previous visit, the department does not have sufficient evidence to determine that staff did not safeguard residents personal belonging. Therefore, the above allegation is UNSUBSTANTIATED at this time.

It was alleged that staff did not prevent inappropriate room accommodations, LPA interview with residents in care revealed that each resident was satisfied with their room accommodations. Interviews with residents further revealed that no resident has ever witnessed any staff members storing their personal belongings in resident bedrooms or sleeping in any of the resident bedrooms. LPA records review revealed there is no live in staff on file at this time. Based on information gathered during this and previous visit, the department does not have sufficient evidence to determine that staff did not prevent inappropriate room accommodations. Therefore , the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent to Administrator via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

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