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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609546
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:09:09 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
02/08/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220208145452
FACILITY NAME:HMS HOMEFACILITY NUMBER:
197609546
ADMINISTRATOR:DAVTIAN, ZHANNAFACILITY TYPE:
740
ADDRESS:14650 RUNNYMEDE STTELEPHONE:
(818) 640-4703
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Zhanna DavtianTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Residents are not provided with essential bathroom supplies.
Facility was malodorous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced complaint visit to the facility today. The LPA met with staff and explained the reason for the visit. There was (2) two staff and (6) six residents present. The Administrator Zhanna Davtian arrived at the facility shortly thereafter and LPA explained the reason for the visit.

During today’s visit, the LPA conducted a plant tour at 10:17 a.m., interviewed residents at 10:55 a.m.,10:57 a.m., 10:58 a.m. and 11:00 a.m., and interviewed staff at 10:31 a.m.,11:06 a.m. and 11:14 a.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
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 5
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
02/08/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220208145452

FACILITY NAME:HMS HOMEFACILITY NUMBER:
197609546
ADMINISTRATOR:DAVTIAN, ZHANNAFACILITY TYPE:
740
ADDRESS:14650 RUNNYMEDE STTELEPHONE:
(818) 640-4703
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Zhanna DavtianTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Facility was unsanitary.
Covid-19 masking protocols are not being followed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced complaint visit to the facility today. The LPA met with staff and explained the reason for the visit. There was (2) two staff and (6) six residents present. The Administrator Zhanna Davtian arrived at the facility shortly thereafter and LPA explained the reason for the visit.

During today’s visit, the LPA conducted a plant tour at 10:17 a.m., interviewed residents at 10:55 a.m.,10:57 a.m., 10:58 a.m. and 11:00 a.m., and interviewed staff at 10:31 a.m.,11:06 a.m. and 11:14 a.m.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
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 29-AS-20220208145452
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: HMS HOME
FACILITY NUMBER: 197609546
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2022
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation (a)(1)…Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is
not met as evidenced by:
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The Administrator agreed to do the following:
Submit a plan of action of how staff manage resident incontinence problems to CCL no later than 2/25/22.
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Based on interviews, the licensee did not comply with the section cited
above, as staff admitted that the floor was soiled due to an incontinent accident, which poses a potential health and safety risk to residents in care.
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Type B
02/25/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit staff retraining log on Infection Control PIN 21-38-ASC regarding masks wearing in the facility to CCL by 2/25/22.
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Based on interviews, the licensee did not comply with the section cited above, as staff admitted to not wearing a mask during prior a incident, which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220208145452
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: HMS HOME
FACILITY NUMBER: 197609546
VISIT DATE: 02/17/2022
NARRATIVE
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Regarding the allegation: Facility was unsanitary. It was alleged that the facility was unsanitary. The LPA spoke to staff and confirmed that there had been an instance where the staff had not cleaned the floor surfaces resulting in a visitor stepping in feces. Interviews reveled that feces on the floor at the time of the visitor’s visit to the facility was due to a resident having an accident. Residents claim that the facility is clean and sanitary on most occasions; staff conducts daily cleaning and additionally cleans throughout the day (3) three to (4) four times a day. Based on the information obtained, there is sufficient evidence to support the claim that the facility was unsanitary. This allegation is deemed Substantiated at this time


Regarding the allegation: COVID-19 masking protocols are not being followed. It was alleged that the facility was not following COVID-19 masking protocols. Interviews conducted revealed that that there had been an instance where the staff were not wearing masks at the time of the visitor’s arrival. Staff confirmed that there had been a moment of 5-10 minutes in the past when staff was not wearing a mask due to health reasons. During today’s visit it was observed that staff were wearing masks upon arrival and throughout the visit. Staff understood the importance of adhering to masking protocols. Based on the information obtained, there is sufficient evidence to support the claim that COVID-19 masking protocols are not being followed. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220208145452
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: HMS HOME
FACILITY NUMBER: 197609546
VISIT DATE: 02/17/2022
NARRATIVE
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Regarding the allegation: Residents are not provided with essential bathroom supplies. It was alleged that residents are not being provided essential bathroom supplies. Interviews and observations conducted revealed that paper supplies are stocked in all bathrooms readily accessible. Staff interviews revealed that they ensure that resident bathrooms are fully stocked with paper towels and toilet paper at all times. Staff ensure to check the paper good supply regularly throughout the day. Residents communicated no concerns as it related to the bathroom supplies, claimed that supplies are readily available and confirmed bathrooms are always kept fully stocked. The LPA observed overstock of paper supplies stored in the garage storage cabinet. Based on the information obtained, there is insufficient evidence to support the claim that residents are not provided with essential bathroom supplies. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility was malodorous. It was alleged that the facility was malodorous. Interviews and observations conducted revealed that there were no malodorous smells in the facility at the time of the visit. Interviews revealed that the facility is maintained clean and sanitary at all times and further revealed no complaints regarding malodorous smells or unsanitary conditions. Interviews reveled that a resident had soiled themselves and soiled the floor at the time of a visitor’s visit to the facility. The incident resulted in the facility being malodorous however the facility ensures regular cleaning protocols to maintain a clean environment. Based on the information obtained, there is insufficient evidence to support the claim that the facility was malodorous. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5