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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850317
Report Date: 01/02/2025
Date Signed: 01/02/2025 03:46:30 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
12/26/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20241226105051
FACILITY NAME:STARLIGHT FACILITY INC.FACILITY NUMBER:
195850317
ADMINISTRATOR:TADEVOSYAN, NELLIFACILITY TYPE:
740
ADDRESS:7647 TUJUNGA AVE.TELEPHONE:
(818) 378-7069
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
01/02/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ruzanna MelikyanTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff mismanaged resident medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial 10-day complaint visit to investigate the above allegation. Upon arrival at approximately 12:00 pm, the LPA was greeted by caregiver, Ruzanna Melikyan who called the Administrator to inform them of the visit. The Administrator Nelli Tadevosyan was not able to be present during today's visit, however was available at any time during face time.

During today's visit the LPA toured the physical plant areas inside and outside and beginning at 12:45 p.m. the LPA conducted a medication audit for two (2) residents, interviewed one residents family member, one (1) resident, and three (3) staff.

Report will continue on LIC9099-C, 2nd page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
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-20241226105051
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: STARLIGHT FACILITY INC.
FACILITY NUMBER: 195850317
VISIT DATE: 01/02/2025
NARRATIVE
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On the allegation, "Staff mismanaged resident medication,"; it is the concern of the reporting party that a resident that lived at the facility long ago, received the wrong medication and almost went into cardiac arrest. No dates and/or other information about the alleged incident were provided. The LPA was unable to determine the resident. However, during a medication audit conducted for two (2) out of five (5) residents’ during today’s visit, the LPA observed the following. During Resident 1 (R1’s) medication audit, the LPA observed that R1’s Gabapentin is prescribed to be give one capsule by mouth two times a day, however the medication bottle was documented on the Centrally Stored and Destruction Record (CSDR) as two capsules being given once a day, and the medication bottle only had an evening sticker placed on the cap of the bottle. Upon observation, staff called the Administrator, and the Administrator explained to the LPA that when the resident arrived at the facility, they were getting two capsules once a day at their previous home and continue to do so at the facility. Additionally, R1’s Melatonin and Vit D2 were counted and had one more pill than they should have based on the date started documented on the CSDR. Upon observation, the Administrator stated that they did not know why the count was off, and when discussing R1’s Vit D2 1.25 MG medication that should be given once a week every Friday and should only have two left but have three pills left, they stated that they probably did not give them one last week.

Based on the information obtained, although there is not sufficient evidence to support a resident went into cardiac arrest due to being given the wrong medication, medication audit revealed that R1 did not received Gabapentin as prescribed and did not receive their Melatonin and Vit D2 medication on one occasion. Therefore, the allegation of “Staff mismanaged resident medication” is deemed substantiated at this time.

Exit interview conducted, deficiency cited, and the report and appeal rights emailed to the licensee.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241226105051
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: STARLIGHT FACILITY INC.
FACILITY NUMBER: 195850317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2025
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions.
This requirement has not been met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding as well as a plan to ensure how they ensure that residents will be provided medications as prescribed and send to LPA via email by COB 1/3/2025.
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Based on interviews and medication audit, the licensee did not comply with the section cited above as R1 did not receive 1 of their medications as prescribed and did not receive 2 of their medications in one occassion,which poses an immediate 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3