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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850075
Report Date: 03/10/2023
Date Signed: 03/10/2023 09:22:22 AM

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 CAREFACILITY NUMBER:
195850075
ADMINISTRATOR:CHARCHYAN, KARINEFACILITY TYPE:
740
ADDRESS:6511 BONNER AVE.TELEPHONE:
(818) 691-3146
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 4DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Hovhannes Ispiryan - Licensee TIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Resident sustained injuries while in care
Staff did not ensure resident was seen by a physician
Staff did not administer residents medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to the deliver findings for the allegation listed above. Upon arrival LPA met with staff and explained the reason for the visit. The licensee Hovhannes Ispiryan arrived shortly thereafter.

During the investigation, LPA conducted a physical plant tour virtually on 01/25/2021, obtained documents and interviewed the Administrator. Subsequent visits were conducted on 06/10/2021 and 08/23/2021 to conduct interviews with staff, residents, responsible parties and obtain additional documents as well as deliver findings on other allegations related to this complaint. LPA made multiple attempts to contact reporting party to obtain additional information on 01/25/2021, 01/26/2021, 08/23/2021, and 02/28/2023, but was unsuccessful.

It was reported that resident sustained injuries while in care, as it was alleged that Resident 1 (R1) was observed to have wounds and bruising on their left arm.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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 3
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: 03/10/2023
NARRATIVE
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Continued from 9099
LPA’s interview with R1’s Private Caregiver 1 (PC1), revealed they assisted R1 with bathing, grooming and dressing at the facility at least twice a week. Interviews further revealed PC1 had never observed any wounds or bruising on R1 while R1 was in care at the facility. LPA interview with Administrator and staff along with records review of R1’s file revealed there was never an observation of wounds or bruising on any part of R1’s body. LPA was unable to obtain additional information from reporting party regarding this allegation. Based on information gathered during this and previous visits, the department does not have sufficient evidence to determine that R1 was ever observed with wounds and bruising. Therefore, the allegation that resident sustained injuries while in care has been deemed UNSUBSTANTIATED at this time.

It was reported that Staff did not ensure resident was seen by a physician, as it was alleged that R1 had not been to a doctor in over a year. LPA records review of R1’s file revealed, that according to physician’s reported dated 08/14/2018, R1 had the following diagnoses and health conditions, COPD exacerbation, blindness, Non-Ambulatory, able to communicate needs, follow instructions and needed some assistance with self-care. File review further revealed there was nothing notated in the change of R1’s health condition upon admittance that would require Licensee to conduct a reappraisal. LPA interview with PC1 and staff, revealed PC1 drove R1 to doctor’s appointments multiple times throughout R1’s stay in the facility. LPA was unable to obtain additional information from reporting party regarding this allegation. Based on information gathered during this and previous visits, the department does not have sufficient evidence to determine that R1 had not been to a doctor in over a year. Therefore, the allegation that staff did not ensure resident was seen by a physician has been deemed UNSUBSTANTIATED at this time.

It was reported that staff did not administer resident’s medication, as it was alleged that staff were not aware of what two (2) medications R1 needed to take. LPA records review of R1’s file and most current centrally stored medication log revealed that prescription Quetiapine Fumarate 25mg, quantity 90 was prescribed to be taken once nightly. The prescription Trazadone 50mg quantity 45 was prescribed for R1 to take ½ a tab at bedtime. No Medication Administration Record on file for LPA to review. LPA interview with PC1 revealed PC1 did not express any concerns of R1 not being administered medication while in care. Interview further revealed PC1 has observed staff administer medications to R1 on multiple occasions. LPA’s interview with family member / responsible parties of residents in care revealed that each were satisfied with the services of the facility staff and each did not express any immediate or potential concerns of staff not being aware of what medications to administer to the residents in care.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
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: 03/10/2023
NARRATIVE
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Continued from 9099-C

LPA was unable to obtain additional information from reporting party regarding this allegation. Based on information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff were not aware of what two (2) medications R1 needed to take. Therefore, the allegation that staff did not administer resident’s medication has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted and copy of report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3