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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608760
Report Date: 10/18/2021
Date Signed: 10/18/2021 05:14:00 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211014122432
FACILITY NAME:NOBLE CAREFACILITY NUMBER:
197608760
ADMINISTRATOR:ARMINE TAGARYANFACILITY TYPE:
740
ADDRESS:13300 ARMINTA STREETTELEPHONE:
(818) 616-2427
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
10/18/2021
UNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Armine Tagaryan TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff not providing assistance to resident(s) in a timely manner.

INVESTIGATION FINDINGS:
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On 10/18/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day complaint investigation visit regarding the above allegation. LPA Urena arrived at the facility at 2:05pm, and met with the Administrator Armine Tagaryan at 2:15pm and explained the purpose of the visit.

At 2:30 pm, LPA Urena and the administrator conducted a tour of the facility, inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The indoor and outdoor of the facility was found to be in working condition. Four out of four bedrooms had adequate furnishings, bedding, personal space and lighting. Two out of two bathrooms were found in clean condition with paper towels for hand drying and signs for washing hands. Kitchen was found to be in clean condition, knives were propertly locked. There was perishable and non perishable food available for six residents and three staff.
Continues on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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 2
Control Number 29-AS-20211014122432
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: NOBLE CARE
FACILITY NUMBER: 197608760
VISIT DATE: 10/18/2021
NARRATIVE
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During the tour of the facility the LPA and Administrator observed residents ask for assistance and caregivers attended promptly to their call. LPA Urena interviewed five out of five residents from 2:45pm to 3:30pm about staff assisting residents in the facility in a timely manner. Interviews revealed that five out of five residents confirmed S3 is providing care and supervision to the residents in a timely manner (at night). Residents stated that when they need assistance they call out for assistance, and staff come to attend their needs. Bedroom doors are kept open at all times of the day and night.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted, today's report was reviewed with administrator. Signatures were obtained, report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2