197607711-7-23-2021-31-AS-NMAN-C69MX7-20210826095930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607711
Report Date: 07/23/2021
Date Signed: 07/23/2021 01:33:46 PM

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
01/28/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200128132406

FACILITY NAME:	OUR SWEET HOME INC		FACILITY NUMBER:	197607711
ADMINISTRATOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	16518 DEVONSHIRE ST		TELEPHONE:	(818) 970-9586
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2021
		UNANNOUNCED	TIME BEGAN:	12:11 PM
MET WITH:	Connie Gayahan - Staff		TIME COMPLETED:	01:27 PM

ALLEGATION(S):

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Staff caused multiple fractures to resident

Staff Interacted with resident in an inappropriate manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to deliver the findings of the above allegations. LPA met with staff Connie Gayahan who called the administrator Tina Arutyunyan and designated her to sign the report. LPA explained the reason for the visit.

Entrance interview conducted.

On 01/28/2020, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was initiated by the LPA Michael Cava and completed by the Investigator Peter Zertuche from the Investigation Branch of Community Care Licensing Division.

During course of investigation, on 01/29/2020 at 9:00 AM, LPA Cava interviewed facility staff, including the staff attending Resident #1 (R1), administrator, and residents. Investigator Zertuche interviewed residents and staff on 01/30/2020. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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 31-AS-20200128132406

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: OUR SWEET HOME INC	FACILITY NUMBER: 197607711
	VISIT DATE: 07/23/2021

NARRATIVE

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(continued from LIC 9099)

In addition, Investigator interviewed R1’s responsible party on 02/11//2020, Reporting Party (RP) on 02/12/2020 and R1 on 02/13/2020.

On 01/29/20, LPA Cava obtained copies of the facility records and on 01/30/2020, Investigator Zertuche obtained hospital medical records.

1. Regarding the allegation that staff caused multiple fracture to residents, it was alleged that the staff cause the fractures on R1's hands and feet.

LPA’s interview with the staff revealed that on 01/24/2020 R1 had an unwitnessed fall in their bedroom. Staff heard R1’s scream and immediately went to assist. R1 denied any pain at that time. The next day, on 01/25/2020, Home Health nurse visited and recommended R1 be brought to the hospital due to complaint of pain.

LPA’s record review on 01/29/2020 verified the information revealed from the staff interview. Records also indicated that R1’s scream was overheard by another resident who saw the staff entering the room, while R1 was on the floor.

Investigator Zertuche’s and LPA Cava’s interview with staff and residents on different dates and different occasion, consistently revealed that no one witnessed nor had any knowledge of any staff hurt or attempted to hurt R1 or any other resident in any way. Investigator Zertuche’s interview with the R1’s responsible party revealed that R1 had a history of falsely accusing the facility staff.

2. Regarding the allegation that staff interacted with resident in an inappropriate manner, it was reported that staff handles R1 inappropriately.

(continued on LIC 9099-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200128132406

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: OUR SWEET HOME INC	FACILITY NUMBER: 197607711
	VISIT DATE: 07/23/2021

NARRATIVE

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(continued from LIC 9099-C)

LPA Cava’s interview with three (3) residents at the facility on 01/29/20 revealed that no staff had been inappropriate with them nor they witnessed any staff being inappropriate with any other resident. IB Investigator Zertuche’s interview with four (4) residents on 01/30/2020 also revealed that they had no complaints regarding the staff and that they treat them well.

Based on information gathered during the course of the investigation, the allegations are deemed unsubstantiated at this time

Exit interview conducted and copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

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