197609606-12-29-2021-31-AS-DPEA-CA8V2R-20211231150331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609606
Report Date: 12/29/2021
Date Signed: 12/29/2021 02:03:40 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 31-AS-20200609153924

FACILITY NAME:	AURORA HOME FOR SENIORS		FACILITY NUMBER:	197609606
ADMINISTRATOR:	MKRTCHYAN, ANI HASMIK		FACILITY TYPE:	740
ADDRESS:	16346 SHAMHART DRIVE		TELEPHONE:	(818) 257-1457
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	12/29/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Armine Arakelyan - Caregiver		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care

Facility staff could not provide resident's authorized representative with the resident's medical information

Facility staff did not notify resident's authorized representative of a change in the resident's condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final investigation finding regarding above allegations. During today’s visit LPA met with caregiver Armine Arakelyan and explained reason for visit. LPA spoke with Administrator Ani Hasmik over the phone who stated that Armine can sign the report.

Following is a summary of the investigation:

On 06/09/2020, the Department received a complaint alleging that Resident #1 (R1) developed multiple pressure injuries while in the facility's care due to staff neglect/lack of supervision.
On 06/11/2020, LPA Chochian conducted the initial complaint visit. Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19), and to implement mitigation measures, the initial complaint investigation was conducted virtually with the use of "Face Time" with Administrator Ani Mkirtchyan.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

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-20200609153924

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AURORA HOME FOR SENIORS	FACILITY NUMBER: 197609606
	VISIT DATE: 12/29/2021

NARRATIVE

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Continued from 9099

During the virtual visit, between the hours from 3:30p.m. to 5p.m., LPA Chochian conducted a virtual physical plant tour with administrator and discussed allegation. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Special Investigator Peter Zertuche.

On 08/26/2020, Special Investigator Zertuche conducted an interview with the reporting party at approximately 11:30a.m.; interview with R1’s responsible person at approximately 12:30p.m.; interview with facility staff on 09/17/2020 at approximately 11a.m. and 11:30a.m. and on 9/22/2020 at approximately 9a.m. Additionally, Special Investigator Zertuche, conducted an interview on 09/23/2020 with ABC Hospice visiting nurse.

During investigation, Investigator Zertuche obtained and reviewed hospital medical records, hospice records, and R1’s facility records. Information gathered revealed that R1 was admitted to the facility on 05/18/2020. ABC Hospice was initiated the same day due to R1’s declining health status. Staff indicated they regularly repositioned R1 every two (2) hours as instructed by hospice nurse. ABC Hospice agency staff interview stated the focus was on R1 declining health due to Alzheimer’s disease, not wound care as R1 did not have any wounds upon start of hospice care. Throughout the stay at the facility, R1 received hospice service twice a week from 05/18/2020 (start of care) – 06/05/2020 (end of care). Hospice records indicate R1 received care services from hospice staff on 05/18/2020; 05/20/2020; 05/21/2020; 05/24/2020; 05/27/2020; 05/30/2020; 06/01/2020; 06/03/2020; and 06/04/2020. Hospice records indicate, wounds did not form until 6/1/2020 – a blister/redness on coccyx area observed on 06/01/2020 and a deep tissue injury to the right foot/heel on 06/03/2020. Facility staff were instructed to continue monitoring R1 and reposition every 2 hours. Hospice notes further reviewed revealed that R1’s family was regularly kept informed by visiting hospice staff of R1’s declining health condition and on 06/05/2020 family decided to have R1 transfer to the hospital. According to hospice staff there was no concerns regarding the care provided by the facility staff took immediate action when they found out about the injuries.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20200609153924

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AURORA HOME FOR SENIORS	FACILITY NUMBER: 197609606
	VISIT DATE: 12/29/2021

NARRATIVE

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Continued from 9099-C

Regarding allegation “Facility staff could not provide resident's authorized representative with the resident's medical information”, it was reported that when R1’s family asked staff about what medications R1 is on and staff did not know. Interview was conducted with facility staff during the initial visit on 06/11/2020 by Licensing Program Analyst Zabel Chochian. Interview with staff revealed that the staff that was asked about R1’s medications at the time did not know because they do not handle medications. Regarding allegation “Facility staff did not notify resident's authorized representative of a change in the resident's condition”. It was reported that the facility did not advise R1’s family that the resident was declining or that the resident's mental status became altered. Interview with facility staff and hospice staff revealed that R1’s family was regularly informed of R1’s declining health status. Several attempts were made to contact R1’s family on 6/11/2020; 08/31/2020 and 09/15/2020; no return call was received.

Based on the above information, there is not enough evidence to support the allegations. Therefore, the allegations are deemed Unsubstantiated at this time.

Exit interview conducted and copy of report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

LIC9099 (FAS) - (06/04)

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