197608083-3-18-2024-31-AS-MVAO-D49MRT-20240412095048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608083
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:38:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/09/2022 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220509135641

FACILITY NAME:	OUR SWEET HOME INC #2		FACILITY NUMBER:	197608083
ADMINISTRATOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	10150 MELVIN AVE		TELEPHONE:	(818) 970-9586
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 4	DATE:	03/18/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Hermon Ledesma (Staff)		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not provide medical assistance to resident while in care.
Staff did not administer medication to resident while in care.

INVESTIGATION FINDINGS:

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On 03/18/2024 Licensing Program Analysts (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival LPA met with staff Hermon Ledesma. Hermon contacted the Administrator, Tina Arutyunyan by telephone and LPA explained the purpose of the visit. Tina could not meet LPA on todays visit and designated Hermon to sign todays report. LPA informed Tina to be available by telephone if LPA called requesting more information.

At approximately 10:25 a.m. LPA conducted a physical plant tour of the facility and interviewed Hermon. At approximately 11:17 a.m. LPA conducted interviews with four (4) out of four (4) residents in the home. At approximately 11:43 a.m. LPA reviewed and obtained resident's #1 (R1's) admission agreement, physician's reports, appraisal needs and services plan, identification and emergency information, and Hopsice records on file. LPA also reviewed facility program in reference to medication procedure and medication documentation. At approxemetly 1:15 p.m. LPA interviewed Tina by telephone. (Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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 31-AS-20220509135641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OUR SWEET HOME INC #2	FACILITY NUMBER: 197608083
	VISIT DATE: 03/18/2024

NARRATIVE

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Allegation #1: Staff did not provide medical assistance to resident while in care. It is alleged resident #1 (R1) had a medical emergency at the facility, and staff did not seek medical attention. To investigate this allegation LPAs Joscelyn Martinez and Tuesday Cabiness conducted an initial complaint investigation on 05/17/2022. They interviewed four (4) residents including R1, interviewed staff present and reviewed and obtained resident records. Interview with residents on 05/17/2022 and 03/18/2024 revealed they are satisfied with the assistance being provided and are confidant staff can determine if they are having a medical emergency and will call 911 if needed. Interview with staff on 03/18/2024, staff denied the allegation and revealed R1 may seek attention sometimes and or omit information from staff later revealing they may have been experiencing symptoms from medication. Interview with staff on 05/17/2022 revealed on day in question staff was present and according to them R1 had reported shortness of breath but then stated they were ok. According to staff they contacted R1's relative and they insisted R1 be taken to the hospital. Discharge paper work obtained by LPA Martinez revealed R1 was recommended a medical procedure. Interview with R1 on 05/17/2022 revealed on the day in question they had complained about shortness of breath but that it was not true. When LPAs asked why R1 stated so, R1 stated they wanted to get out of the facility because they felt stuck there. R1 went on to state they did not feel ill and were not experiencing any symptoms. Based on information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time.

Allegation #2: Staff did not administer medication to resident while in care. It is alleged facility failed to provide medication during the time R1 was discharged from Hospice. To investigate this allegation on 05/17/2022 LPAs review of Medication Administration Records (MAR) for the time period in question revealed medication listed on MAR was provided. Interviews with four (4) residents on 05/17/2022 and four (4) out of four (4) residents on 03/18/2024 revealed they cannot recall ever experiencing missed medication, or medication errors. According to interview on 03/18/2024 with staff responsible for assisting residents with medication they deny the allegation and they state they have always provided medication as directed. On 03/18/2024 LPA's review of R1's physician's report for examination done on 06/24/2022, revealed R1 was not receiving Hospice care and a terminal illness was not specified. According to a telephone interview with Administrator on 03/18/2024, R1 was discharged from Hospice and not receiving Hospice care for about two years. Administrator states R1 is now receiving Hospice care. LPA's review of R1's Hospice records revealed last entry was made on 05/20/2021 for a medication that LPA reviewed on MAR was documented as being provided during period in question. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC9099 (FAS) - (06/04)

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