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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850306
Report Date: 05/13/2025
Date Signed: 05/13/2025 02:39:34 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
05/12/2025 and conducted by Evaluator Angela Barutyan
COMPLAINT CONTROL NUMBER: 29-AS-20250512123236
FACILITY NAME:AAA JERUSALEM STARSFACILITY NUMBER:
195850306
ADMINISTRATOR:SOHEILA NOROOZIFACILITY TYPE:
740
ADDRESS:5945 CAPISTRANO AVETELEPHONE:
(818) 888-1706
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kristina AdamyanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are unable to communicate effectively
Staff mishandled a client while in care
Staff did not provide adequate care and supervision to a client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegations listed above 11:00AM. Upon arrival, LPA met with staff and Administrator Kristina Adamyan who arrived at 11:40AM. Entrance interview conducted.

During today's visit, LPA conducted a physical plant tour upon entry, interviewed three (3) of six (6) residents between 11:04AM-11:35AM as two (2) residents were asleep and one (1) resident was away from the facility during the visit, interviewed two (2) staff and the Administrator between 11:36AM-12:10PM, reviewed and obtained copies of pertinent documents relevant to the investigation at approximately 12PM, and discussed allegations with Administrator at 02:27PM.

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

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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-20250512123236
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 JERUSALEM STARS
FACILITY NUMBER: 195850306
VISIT DATE: 05/13/2025
NARRATIVE
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It was alleged that staff are unable to communicate effectively due to language barriers. Two (2) out of three (3) residents interviewed stated that there is a language barrier with staff, but that staff understand basic English and use translators on their phone for clarification. Residents expressed no immediate concerns of staff unable to understand or assist residents. Residents stated that staff make the effort to understand and use other means such as hand gestures, online translators, and calling the Administrator for translation whenever necessary. LPA interviewed two (2) of two (2) staff and observed that staff were able to communicate in English and understand LPA. Staff #1 (S1) was able to state the types of abuse and resident personal rights. Staff #2 (S2) was unable to state the types of abuse and personal rights in English, but was knowledgeable in their language after LPA used a translator. Staff stated that there is a language barrier at times, but they use multiple methods to ensure that staff and residents understand one another. LPA reviewed training records and observed medication, dementia care, and annual caregiving training within the past year. Administrator stated that S2 will be getting additional training in English. Based on interviews, observation, and record review, the information obtained during the investigation does not have sufficient evidence 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 above allegation “Staff are unable to communicate effectively” is deemed UNSUBSTANTIATED at this time.

It was further alleged that staff mishandled Resident #1 (R1) by dropping them after a wheelchair transfer and leaving them unsupervised. Interviews with residents, staff, and Administrator revealed that on 05/09/2025, R1 was using their new electric wheelchair but had not yet received proper instructions for use as the chair was received on 05/08/2025. R1 was outside with staff supervision and began to slip from the chair. R1 asked S1 and S2 for assistance and staff assisted R1 by lifting R1 up and into a more secure position on the chair. R1 stated they were in pain after the transfer assistance. Staff called the Administrator who called 9-1-1 and the paramedics transferred R1 to the hospital upon request. R1 returned same day with no new orders or changes of condition. R1 stated they do not fault the staff for the incident. R1 had a catheter pump that was located towards their back where staff pulled R1 up from. Paramedics and R1 were concerned that the pump could have moved but after further evaluation at the hospital, it was determined that the pump was intact. R1 and staff stated that R1 was being supervised outside and at no time were they left alone.
Report Continued on LIC 9099-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250512123236
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 JERUSALEM STARS
FACILITY NUMBER: 195850306
VISIT DATE: 05/13/2025
NARRATIVE
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LPA interviewed two (2) other residents who expressed no concerns of lack of supervision, inadequate care, or mishandling. LPA reviewed the staff roster which indicated adequate staff coverage at all times. During the visit, LPA reminded Administrator of reporting requirements and to submit a written incident report to the Department within seven (7) days of occurrence. Administrator stated they will submit the report. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence 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 above allegations “Staff mishandled a client while in care” and “Staff did not provide adequate care and supervision to a client” are deemed UNSUBSTANTIATED at this time.

Administrator designated staff Karyna Deputativa to sign the report.

No deficiencies cited at this time. Exit interview conducted telephonically with Administrator. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3