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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850178
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:16:43 PM

Substantiated


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
06/22/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230622091834
FACILITY NAME:MONOGRAM VILLAFACILITY NUMBER:
195850178
ADMINISTRATOR:KRBASHYAN, AZNIV ANGELAFACILITY TYPE:
740
ADDRESS:5536 TYRONE AVETELEPHONE:
(818) 808-7792
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 5DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Angela Azniv KrbashyanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility visiting hours are unreasonable.
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 12:34 p.m., the LPA met with staff and explained the reason for the visit. At 12:58 p.m., the Administrator, Angela Azniv Krbashyan arrived at the facility.

During the initial visit conducted on 06/27/2023 between 9:25 a.m. and 12:15 p.m., LPA Peraldi conducted interviews with the Administrator, two (2) staff and five (5) residents. The LPA also conducted a physical plant tour, reviewed records and obtained copies of pertinent documents. During the initial visit, the LPA also conducted interviews with a home health nurse and a physical therapist and a resident’s family member.

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

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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
Control Number 29-AS-20230622091834
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: MONOGRAM VILLA
FACILITY NUMBER: 195850178
VISIT DATE: 11/06/2024
NARRATIVE
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Regarding the allegation: 1.) Facility visiting hours are unreasonable. On 06/22/2023, the Department received a complaint alleging that the facility’s visiting hours are unreasonable. During the initial visit, the LPA observed the facility’s visiting hours posted as Monday- Sunday 10 a.m. – 12:00 p.m. and 2:00 p.m. – 7:00 p.m. Interview conducted with the Administrator revealed that the visiting hours are not enforced, and families stay past 7:00 p.m. The Administrator explained that the gap between the visiting hours is for staff to take their lunches. The Administrator stated that she will change the visiting hours to more reasonable times such as 9:00 a.m. to 9:00 p.m. Based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230622091834
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: MONOGRAM VILLA
FACILITY NUMBER: 195850178
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/15/2024
Section Cited
CCR
87468.1(a)(11)
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87468.1 (a) (11) Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all...:(11)To have their visitors
...permitted to visit privately during reasonable hours… This requirement has not been met as evidenced by:
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The Administrator already changed the visiting hours, plan of correction met.
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Based on interview and observations, the licensee did not comply with the section cited above as the visiting hours are unreasonable which poses a potential health and safety 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/22/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230622091834

FACILITY NAME:MONOGRAM VILLAFACILITY NUMBER:
195850178
ADMINISTRATOR:KRBASHYAN, AZNIV ANGELAFACILITY TYPE:
740
ADDRESS:5536 TYRONE AVETELEPHONE:
(818) 808-7792
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Angela Azniv KrbashyanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff are not serving an adequate amount of food to residents.
Facility does not provide a menu for residents in care.
Facility staff speaks in an aggressive tone towards a resident.
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 12:34 p.m., the LPA met with staff and explained the reason for the visit. At TIME, the Administrator arrived at the facility.

During the initial visit conducted on 06/27/2023 between 9:25 a.m. and 12:15 p.m., LPA Peraldi conducted interviews with the Administrator, two (2) staff and five (5) residents. The LPA also conducted a physical plant tour, reviewed records and obtained copies of pertinent documents. During the initial visit, the LPA also conducted interviews with a home health nurse and a physical therapist and a resident’s family member.

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

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230622091834
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: MONOGRAM VILLA
FACILITY NUMBER: 195850178
VISIT DATE: 11/06/2024
NARRATIVE
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Regarding the allegations: 1.) Facility staff are not serving an adequate amount of food to residents. 2.) Facility does not provide a menu for residents in care. On 06/22/2023, the Department received a complaint alleging residents not being fed enough and not being provided a menu. During the initial visit, the LPA observed the kitchen with two (2) refrigerators with sufficient amount of perishable and nonperishable food. The LPA also observed a sample menu in the kitchen. Per 87555 General Food Service Requirements, “Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file.” Interviews conducted with residents did not voice concerns regarding the food being served. Interview with the Administrator revealed that grocery shopping is done weekly or as needed. Additionally, the Administrator provided the LPA pictures of previous meals served to the residents. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed Unsubstantiated at this time.

Regarding the allegation: 3.) Facility staff speaks in an aggressive tone towards a resident. On 06/22/2023, the Department received a complaint alleging staff speaking aggressively toward a resident. Resident interviews revealed that staff are kind and did not voice any concerns regarding staff. Staff interviews revealed that staff have not heard staff speak aggressively towards residents. Interviews conducted with home health nurse, physical therapist and resident’s family member did not reveal any concerns with staff and stated staff treat residents with respect. Interview with the Administrator denied staff speaking aggressively towards residents, however stated staff sometimes speak louder in order for some residents to hear since some residents are hard of hearing. 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: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5