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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850166
Report Date: 12/31/2024
Date Signed: 12/31/2024 12:34:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/07/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230907155842
FACILITY NAME:AAA QUALITY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
195850166
ADMINISTRATOR:KIRAKOSYAN, ELENFACILITY TYPE:
740
ADDRESS:7843 STANSBURY AVE.TELEPHONE:
(323) 485-4851
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 6DATE:
12/31/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ovsanna KhayalyanTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are not ensuring resident's hearing aid is replaced.
Staff are not providing resident with mail.
Staff are not meeting resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 11:00 a.m., the LPA met with staff and explained the reason for the visit. At 11:27 a.m., the Licensee, Ovsanna Khayalyan arrived at the facility.

During the initial visit conducted on 9/14/2023 between 2:15 p.m. and 3:35 p.m., LPA Sandra Urena conducted a physical plant tour and conducted an interview with the Licensee. During the initial visit, the LPA also obtained copies of pertinent documents. During today’s visit, at 11:30 a.m., LPA Peraldi conducted an interview with the Licensee.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
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 2
Control Number 29-AS-20230907155842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AAA QUALITY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850166
VISIT DATE: 12/31/2024
NARRATIVE
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Regarding the allegation: Staff are not ensuring resident's hearing aid is replaced. It was alleged that Resident #1’s (R1’s) hearing aid was not operable, and the Licensee did not assist with replacing the hearing aid. The Licensee stated that she made an appointment for R1 to a hearing center, and the appointment was set for 08/07/2023, but R1 had left to a Skilled Nursing Facility (SNF) in July 2023. R1 did not come back to the facility until 09/02/2023. The Licensee provided the LPA with the appointment card for R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.
Regarding the allegation: Staff are not providing resident with mail. It was alleged that the Licensee would not provide R1 with R1’s mail. The Licensee stated that she would give R1’s mail to R1 and that she would keep R1’s mail at the front of the facility for R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff are not meeting resident's needs. It was alleged that R1 was not taken care of properly as R1 developed wounds while in care. Per record review, R1 was admitted to the facility on 05/06/2023 and left around July 2023 and was readmitted on 09/02/2023. R1’s primary diagnosis upon admission per physician report dated 5/4/2023 is listed as severe sepsis, acute chronic renal failure, acute chronic respiratory failure, atrial fibrillation (afib), bilateral pneumonia, and chronic obstructive pulmonary disease (COPD). R1 also had Mild Cognitive Impairment (MCI). Per physician report dated 5/4/2023, R1 was not on hospice services. R1 did start receiving hospice services on 05/23/2023. Medical records for R1’s hospitalization on 6/27/2023 did not note any pressure ulcers. R1 was at a Skilled Nursing Facility (SNF) from around July 2023 and returned back to the facility on 09/02/2023. The Licensee stated that from the SNF, R1 developed the pressure ulcers. The Licensee stated that she readmitted R1 since R1 would be getting wound care with hospice. Physician report dated on 9/2/2023, noted R1 had pressure ulcers stage 3 and stage 4 on ankles. R1’s physician report dated 9/2/2023, stated that R1 was receiving hospice services. R1’s medical record dated 8/30/2023 stated that R1 had a pressure ulcer on left ankle, stage 4. The LPA called the SNF to confirm that R1 was admitted between July 2023 and September 2023. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2