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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850227
Report Date: 06/21/2024
Date Signed: 06/21/2024 12:31:53 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
05/29/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240529090218
FACILITY NAME:AMERIHOME, INCFACILITY NUMBER:
195850227
ADMINISTRATOR:SARGSYAN, JASMINE HFACILITY TYPE:
740
ADDRESS:17019 MARLIN PLTELEPHONE:
(818) 441-3590
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: DATE:
06/21/2024
UNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Jasmine SargsyanTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff yells at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to deliver findings for the above allegation. Upon arrival, LPA met with caregivers Irina Safaryan and Marieta Kirakosyan. Caregiver Irina contacted the Administrator by phone, Jasmine Sargsyan, and subsequently transferred the call the LPA. LPA explained the reason for the visit, moreover, Administrator informed the LPA that she would not be able to be present to the reading of findings. Administrator requested a conference call between her and her caregivers at the time LPA will read report. Additionally, Administrator authorized caregiver, Irina, to sign today's report.

At 11:10 am LPA along caregiver Marieta toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. At 11:35 a.m. caregivers contacted Administrator so LPA can read report findings.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
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 3
Control Number 29-AS-20240529090218
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: AMERIHOME, INC
FACILITY NUMBER: 195850227
VISIT DATE: 06/21/2024
NARRATIVE
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Continued from LIC 9099

Entrance interview conducted.

It was alleged that facility staff yell at residents. It was further reported that unknown staff member yells at residents to “shut up, be quiet and go to your room”. On 05/30/2024, LPA Conway conducted the initial visit. During the visit, at 10:01 a.m. LPA conducted a physical plant tour; as well, as interviewed five (5) residents, staff and administrator.

Additionally, LPA requested and reviewed facility documentation pertinent to this investigation. Interviews conducted during the course of the investigation reflected that three (3) out of the five (5) residents interviewed have witnessed Staff #1 (S1) yell at residents on multiple occasions. The other two (2) residents interviewed revealed they have not witnessed staff yell at any resident, but they stated that the aggressive and stern manner S1 speaks to residents could be observed as verbal abuse.

LPA's interviews with S1 denied yelling at any resident in care. LPA’s interview with Administrator revealed they have not witnessed S1 yell or mistreat any resident in care but expressed that it may be S1’s mannerisms of speaking loudly and “talking with their hands” that may make it appear S1 is yelling at residents in care.

Based on the information obtained through the course of the investigation, there is sufficient evidence to support the allegation “Staff yelled at resident.” Therefore, this allegation is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit Interview Conducted. Failure to correct the deficiencies may result in civil penalties. Appeal Rights Discussed. A Copy of Report Issued. Exit interview was conducted with the administrator. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240529090218
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: AMERIHOME, INC
FACILITY NUMBER: 195850227
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall... personal rights: (1) To be accorded dignity in... relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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 Licensee will provide training on working with individuals with behavioral issues. Licensee will counsel S1 on treating residents with dignity and respect and review regulation cited.
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Based on interviews, licensee did not comply with the above section by staff # 1 not according dignity to residents in care which is a potential personal rights risk to residents in care.
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Licensee will send CCL the training sign-in sheet, signed by staff by 07/05/2024.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
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