195850323-4-20-2023-29-AS-DPEA-CRASQ2-20230427140400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850323
Report Date: 04/20/2023
Date Signed: 04/20/2023 10:49:25 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/09/2023 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20230309110540

FACILITY NAME:	COMFORT ZONE CAL		FACILITY NUMBER:	195850323
ADMINISTRATOR:	TAVITIAN, HRIPSIME RIPA		FACILITY TYPE:	740
ADDRESS:	13303 REEDLEY STREET		TELEPHONE:	(310) 430-0075
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 1	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Hripsime Tavitian		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Licensee neglect resulted in resident sustaining injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 03/16/2023 by LPA Arroyo. On today’s visit, LPA Arroyo met with Administrator, Hripsime Tavitian and the reason for the visit was explained. Entrance interview.

During the initial visit on 03/16/2023, LPA Arroyo toured the facility at 11:22am, conducted interviews with the Administrator, one staff, and one resident between 10:03am and 11:05am, and conducted a record review and obtained copies of pertinent documents at 10:38am. The LPA also obtained copies of medical documents on 04/10/2023 and conducted a telephonic interview with resident's family member on 04/18/2023 at 12:48pm.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230309110540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT ZONE CAL	FACILITY NUMBER: 195850323
	VISIT DATE: 04/20/2023

NARRATIVE

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Report Continued from LIC 9099...

It was alleged that licensee neglect resulted in resident sustaining injuries while in care. It was reported that Resident #1 (R1) had an unwitnessed ground level fall while living at the facility resulting in R1 obtaining a potential subdermal hematoma and subarachnoid hemorrhage. Additionally, RP had concerns because R1 had had two (2) within a few days. Review of documents revealed that on R1’s Physician’s Report dated 02/22/2023, indicates R1 is non-ambulatory and is able to independently transfer to and from bed. Correspondingly, R1 was able to walk around with a walker. Interviews with staff revealed R1 tried to get out of bed at night that resulted in R1 having an unwitnessed fall. The staff stated hearing a loud noise which prompted them to check on R1. Staff added that R1 usually called staff when they needed assistance. Interview with resident revealed facility staff often come inside the rooms and check on the residents and stated they have no concerns living at the facility. Additionally, interviews conducted with R1’s family revealed the facility had contacted and reported the falls shortly after they had happened. R1’s family stated that before R1’s first fall, both R1’s family and facility had made a request to attempt and have R1’s Primary Care Physician (PCP) order rails to be placed on the side of R1’s bed; however, R1’s PCP was not responding to the request and was taking too long for the approval. Furthermore, R1’s family stated they do not feel there was any type of neglect from the staff or facility. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “licensee neglect resulted in resident sustaining injuries while in care”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and a copy was issued to the Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

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