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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608579
Report Date: 01/19/2023
Date Signed: 01/19/2023 10:55:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/30/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201030121542
FACILITY NAME:NO PLACE LIKE HOME FOR GOLDEN AGESFACILITY NUMBER:
197608579
ADMINISTRATOR:EMMA TOPADZHIKYANFACILITY TYPE:
740
ADDRESS:1459 WESTERN AVENUETELEPHONE:
(818) 245-6799
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY:6CENSUS: 5DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emma TopadzhikyanTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident developed pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra arrived to this facility and met with Emma Topadzhikyan. The purpose of today's visit is to deliver findings for the above allegation.

On 11/03/2020, Licensing Program Analyst (LPA) Elizabeth Irra initiated a complaint investigation for the allegation noted above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the initial complaint investigation was conducted telephonically with Emma Topadzhikyan (Facility Administrator). At approximately 9:15 A.M, LPA Irra spoke to the Facility Administrator via telephone. LPA requested the following: Resident and Staff rosters with contact information. LPA also requested Facility Administrator to submit the following for Resident #1 and Resident #2 (R-1 and R-2): Emergency Contact Information, Pre-Placement Appraisal, Appraisal Needs and Services Plan, Admission Agreement, Power of Attorney (POA) documentation, Physician's Report (annual exam), Dental Consultation records, Medication Administration Records (MAR's) for September 2020 and October 2020, Daily notes for September 2020 and October 2020 and Hospice notes from September 2020 and October 2020. At approximately 1 P.M., LPA conducted a tele-visit tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats. *Refer to LIC 9099C for continuation.*
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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 5
Control Number 28-AS-20201030121542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579
VISIT DATE: 01/19/2023
NARRATIVE
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The investigation for this allegation was conducted by Investigator Peter Zertuche.

During the course of this investigation, Investigator Zertuche, reviewed hospice records in which indicate the victim (R-2) was admitted to this facility on 10/13/2020 “without impairments but after a few days, two pressure injuries began to form. The facility was directed to reposition every two hours, but it was noted on hospice records that the victim (R-2) was in the same position during every nurse visit. Approximately one week after being admitted to the facility, the victim’s (R-2) pressure injuries worsened and on October 28, 2020, the injury was unstageable. Hospice records also noted that the facility did not reposition as necessary and poor care was provided.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.



Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Resident developed pressure injuries while in care.

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(B)(i) and may be assessed at a later date.

Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to Emma Topadzhikyan
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20201030121542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87411(a)
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Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and
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Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87411(a) Written POC must be submitted to CCL by the POC due date.

**Immediate Civil Penalties will be assessed in the amount of $500.00.**
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as required in Section 87608, Postural Supports.

This standard is not met at evidence by: Please refer to page (4) of the LIC 9099 report for details.
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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: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/30/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201030121542

FACILITY NAME:NO PLACE LIKE HOME FOR GOLDEN AGESFACILITY NUMBER:
197608579
ADMINISTRATOR:EMMA TOPADZHIKYANFACILITY TYPE:
740
ADDRESS:1459 WESTERN AVENUETELEPHONE:
(818) 245-6799
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY:6CENSUS: 5DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emma TopadzhikyanTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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2
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Resident's hygiene needs are not being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Emma Topadzhikyan and discussed the purpose of today's visit.

On 11/03/2020, Licensing Program Analyst (LPA) Elizabeth Irra initiated a complaint investigation for the allegation noted above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the initial complaint investigation was conducted telephonically with Emma Topadzhikyan (Facility Administrator). At approximately 9:15 A.M, LPA Irra spoke to the Facility Administrator via telephone. LPA requested the following: Resident and Staff rosters with contact information. LPA also requested Facility Administrator to submit the following for Resident #1 and Resident #2 (R-1 and R-2): Emergency Contact Information, Pre-Placement Appraisal, Appraisal Needs and Services Plan, Admission Agreement, Power of Attorney (POA) documentation, Physician's Report (annual exam), Dental Consultation records, Medication Administration Records (MAR's) for September 2020 and October 2020, Daily notes for September 2020 and October 2020 and Hospice notes from September 2020 and October 2020. At approximately 1 P.M., LPA conducted a tele-visit tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats. *Refer to LIC 9099C for continuation.*
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20201030121542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579
VISIT DATE: 01/19/2023
NARRATIVE
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Allegation: Resident's hygiene needs are not being met. During today’s visit, LPA interviewed Resident #3 (R-3), Resident #4 (R-4) and Resident #5 (R-5). LPA was unable to interview Resident #6 (R-6) as R-6 was asleep at the this of this visit. LPA was unable to interview Resident #1 (R-1) and Resident #2 (R-2) as they no longer reside at this facility. LPA also interviewed Staff #1 through Staff #3 (S-1 through S-3). Resident interviews revealed that staff provide assistance with residents’ hygiene needs. Interviewed residents indicated they do not have any concerns and that their hygiene needs (including dental) are being met by staff. Staff interviews revealed that staff assist resident with their hygiene needs including oral hygiene on a daily basis. Interviewed staff indicated that staff do not keep a log to reflect that residents were assisted with oral hygiene. Interviewed staff indicated they have not received any complaints/concerns in regards to residents hygiene needs not being met. During this visit, LPA also observed staff assisting residents with their hygiene needs and also observed residents to have hygiene supplies. Resident and staff interviews do not corroborate this allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore this allegation is unsubstantiated.

Exit interview conducted and appeal rights and a copy of this report was provided to Emma Topadzhikyan.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5