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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609651
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:12:49 PM

Document Has Been Signed on 08/26/2021 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA CATHERINE SENIOR CARE FACILITYFACILITY NUMBER:
197609651
ADMINISTRATOR:LUSINE I. ABRAMYANFACILITY TYPE:
740
ADDRESS:7001 VAN NOORD AVETELEPHONE:
(818) 279-4309
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 3DATE:
08/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Harut Manukyan - Caregiver TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20210210152037). LPA met withvHarut Manukyan caregiver. LPA spoke with Lusine over the phone and she stated Harut can sign in her place. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
On 02/22/2021, between 12:38pm and 2:00pm, LPA Balisi conducted an initial 10-day virtual visit, at which time, copies of pertinent documents from Resident 1’s (R1) facility file was requested; and, a virtual tour of the physical plant was conducted. Based on the nature of the allegation, the complaint was referred to Community Care Licensing Department’s Audit Division and General Auditor, Lisa Ni conducted the investigation.

On 2/26/2021, Auditor Ni conducted interviews with Pacific Western Bank Rosemead Branch staff and family members of R1. Auditor Ni also obtained and reviewed R1’s facility documents, and Pacific Western Bank Rosemead Branch’s surveillance video footage from 2/9/2021 between 12:34:55pm to 13:12:27pm.

It was reported, that since 02/1/2021, checks were made out to “CASH” in R1’s name, in the amounts of $6,400, $6,000, $4,000 and $2,020. It was also reported that Staff 1 (S1), accompanied R1 to the bank and identified themselves as R1’s Power of Attorney (POA).



Information gathered and reviewed during the course of the investigation revealed that in early February 2021, R1’s family members received a call from Pacific Western Bank Rosemead Branch informing R1’s family that there were several suspicious checks in R1’s name made out to cash and to other entities. There were (5) written checks totaling in the amount of $22,400:
Continued on 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA CATHERINE SENIOR CARE FACILITY
FACILITY NUMBER: 197609651
VISIT DATE: 08/26/2021
NARRATIVE
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$4,000 made out to S1
$6,250 made out to cash
$6,400 made out to cash
$3,550 made out to Golden Century
$2,200 made out to Silver Hospice Care Inc.

The auditor’s interview with Pacific Western Bank Rosemead Branch banking staff revealed they had known R1 for about one year and that the signature on the checks were not consistent in comparison with R1’s signature depicted on the bank signature card. The banking staff stated when R1 was living by themselves, the monthly expense payments were usually utility bills and insurance. Payments were normally in the range of $50 to $100. The banking staff further revealed that on 2/1/2021, after multiple attempts to contact R1 and noticing multiple red flags, R1’s account was frozen to ensure no checks were cleared. It was further revealed that on 02/08/2021, the Pacific Western Bank Rosemead Branch received a phone call from someone pretending to be R1. The branch staff knew it was not R1 because of the different type of voice. The branch staff also knew R1 was having memory loss and/or mental illness. The individual who called in seemed to be very coherent. Later, the branch staff found out that this individual was a worker from the facility where R1 was residing. This individual wanted to find out why R1’s checks were being returned and if the bank could provide the process for adding a POA (Power of Attorney) to R1’s accounts. The branch staff did not give information to this individual because the branch staff knew this individual was not R1. On the same day, S1 called Pacific Western Bank Glendale Branch asking for the same information. The Glendale Branch did not give the information either and referred S1 to the Pacific Western Bank Rosemead Branch.

On 02/09/2021, S1 brought R1 to the Pacific Western Bank Rosemead Branch. The branch manager spoke with R1 first, away from S1, to have a private conversation. R1 seemed to be very confused. R1 said they were in a car accident a week prior, and then R1 said they were in jail. R1 wanted the branch manager’s help to get them out. R1 was calling Villa Catherine Senior Care Facility a jail. R1 did not know who S1 was, and why they were at the branch. R1 was unable to verify all the checks that were returned by bank. After speaking with R1, the branch manager spoke with S1. S1 informed the branch manager that S1 was a long-time friend of the facility and just wanted to get paid for the care that R1 has been receiving. S1 provided the branch manager with R1’s hospital documents and documents showing that R1 was assigned to Villa Catherine Senior Care Facility.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA CATHERINE SENIOR CARE FACILITY
FACILITY NUMBER: 197609651
VISIT DATE: 08/26/2021
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In addition, S1 informed the branch manager that S1 had a Power of Attorney (POA) over R1. The branch manager asked if S1 could provide a copy of the POA documents by email. S1 replied yes. S1 also informed the branch manager that R1 has a family member who was a witness to the power of attorney. However, up to current, S1 never sent the branch a copy of the alleged POA documents.

The auditor’s review of the video surveillance on 2/9/2021, revealed an unknown individual and S1 brought R1 to the Pacific Western Bank Rosemead Branch bank. The branch staff had a private conversation with R1 first at 12:36:54pm. Then, the branch staff had another private conversation with S1 at around 13:12:27pm.

During the course of the auditor’s investigation, R1’s monthly bank statement, Pacific Western Bank Rosemead Branch surveillance cameras, R1’s family members statement and the bank manager’s statement were received and reviewed. It was determined that the licensee’s relative/friend, S1, stole R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account. Due to the unusual checks that were written and the unfamiliar signature, which did not match with the bank records, the bank froze R1’s account immediately. The forged checks were not cleared and there was no financial loss in R1’s bank account. However, based on information obtained through the Auditor’s investigation,

Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 809-D).

Exit interview conducted, appeal rights discussed, and a copy of this report has been issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/26/2021 03:12 PM - It Cannot Be Edited


Created By: Brian Balisi On 08/26/2021 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA CATHERINE SENIOR CARE FACILITY
FACILITY NUMBER: 197609651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/03/2021
Section Cited
HSC
87506(c)(1)

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87506 (c)(1) Resident Records - The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents...make available confidential information only upon the resident’s written consent or that of his designated representative.
This requirement was not met as evidenced by:
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Licensee agreed to review 87506(c)(1) and provide LPA a written statement on how they will prevent a repeat violation. Licensee will send statement to LPA via email by POC date.
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Based on Auditors, record review, the licensee did not ensure that resident financial records were kept confidential. This poses a potential risk to the personal rights and safety of R1.
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Type B
09/03/2021
Section Cited
HSC87468.1(14)

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87468.1(14) – Personal Rights of Resident - To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.

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Licensee agreed to review 87468.1(14) and provide LPA a written statement on how they will prevent a repeat violation. Licensee will send statement to LPA via email by POC date.
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Based on Auditor’s interviews, the licensee did not provide access to a telephone for R1. This poses a potential risk to the to the personal rights and safety of R1.
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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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2021 03:12 PM - It Cannot Be Edited


Created By: Brian Balisi On 08/26/2021 at 01:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA CATHERINE SENIOR CARE FACILITY
FACILITY NUMBER: 197609651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/03/2021
Section Cited
HSC
87405(3)

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87405(3) Administrator – Qualifications and Duties – Ability to maintain or supervise the maintenance of financial and other records.

This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide documentation of scheduled training for Administrator and staff. Licensee will send documentation by POC date.
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Based on Auditors interviews and record review, the licensee’s relative/ friend was able to access R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account, which potential health and personal rights risk to persons 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


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