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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606792
Report Date: 01/05/2022
Date Signed: 01/05/2022 10:42:23 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20211118091106
FACILITY NAME:LUXOR LIVINGFACILITY NUMBER:
197606792
ADMINISTRATOR:SAMEA HELMANDIFACILITY TYPE:
740
ADDRESS:17835 PARTHENIA STREETTELEPHONE:
(818) 687-6877
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 5DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Samea Helmandi, Administrator TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff over medicated resident.
Facility staff cut residents hair against their will.
INVESTIGATION FINDINGS:
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At 9:30 Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with the Administrator, Samea Helmadi, and explained the reason for the visit.

Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. LPA conducted a physical walk through, at approximately, 9:50am to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during this visit.

An initial 10-day complaint visit conducted on 11/24/21. During that visit LPA Panushkina conducted interviews (between 12:00pm – 1:30pm) with the Administrator and five (5) out of six (6) residents and reviewed facility records. File records consisted, but were not limited to review of the Physician’s Report, Resident Care Plans, Relevant Logs, etc. Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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 2
Control Number 31-AS-20211118091106
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LUXOR LIVING
FACILITY NUMBER: 197606792
VISIT DATE: 01/05/2022
NARRATIVE
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In addition, LPA requested Medical Records from Kaiser Permanente on 12/06/21 and received the results on 12/28/21.

Allegation: Facility staff over medicated resident.

Interview with an Administrator indicated that all residents were given medication based on their Physician's order and that the residents get their proper dosage of medication at all time. Interviews with one (1) out of five (5) residents, who were able to communicate, also indicated that the medications were given on time and with the right dosage. In addition, Medical Records received on 12/28/21 from Kaiser Permanente, regarding R1, indicated negative results to “over medication” from the lab test conducted on 11/09/21. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time.

Allegation: Facility staff cut residents hair against their will.

Interviews with an Administrator and one (1) out of five (5) residents, who were able to communicate, indicated that no resident gets a haircut against their will. In addition, LPA was provided with pictures of R1 from October 2020 to November 2021 and LPA observed that the shoulder length haircut within that one year was the longest hair length R1 had. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2