197609651-2-2-2023-29-AS-JAPL-CNU3EE-20230207171100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609651
Report Date: 01/31/2023
Date Signed: 02/02/2023 09:07:06 AM

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
01/30/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230130101515

FACILITY NAME:	VILLA CATHERINE SENIOR CARE FACILITY		FACILITY NUMBER:	197609651
ADMINISTRATOR:	VIKTORYA HAYRAPETYAN		FACILITY TYPE:	740
ADDRESS:	7001 VAN NOORD AVE		TELEPHONE:	(818) 279-4309
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Ruzanna Sukiassyan		TIME COMPLETED:	01:27 PM

ALLEGATION(S):

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Resident sustained an injury while in care.

INVESTIGATION FINDINGS:

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On 01/31/2023, Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced initial10-day visit to investigate the allegation listed above. The LPA arrived at the facility at 11:08 a.m. and was greeted by staff. Staff contacted the Administrator via telephone. Administrator stated they were on their way to the facility.The LPA met with the Administrator Ruzanna Sukiassyan, at 11:20 a.m. and explained the reason for the visit.

At 11:25 a.m. the LPA and the Administrator conducted a brief tour of the physical plant. The LPA interviewed the Administrator from 11:30 a.m. to 12:02 p.m., and conducted records review at 12:05 p.m.

Continues on LIC 9099 C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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 29-AS-20230130101515

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: VILLA CATHERINE SENIOR CARE FACILITY	FACILITY NUMBER: 197609651
	VISIT DATE: 01/31/2023

NARRATIVE

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On the allegation that ‘The resident sustained an injury while in care’, the complainant’s concern is that the resident (R1) sustained a left heel eschar while residing at the board and care. The R1 was admitted to the hospital due to weakness, and was still in the hospital when the LPA conducted the visit to the facility. The LPA interviewed the complainant on 01/30/2023 from 3:31 p.m. to 3:52 p.m. Per the complainant, R1 presented an eschar on the left heel, and discoloration on the lower part of the legs, consequently the reason for the allegation. The complainant stated that after the allegation was submitted to Community Care Licensing Division(CCLD), they communicated with R1’s primary physician, who also practices out of the hospital where R1 is currently admitted. Per the physician’s statement, the discoloration on the lower part of the legs, and the eschar is due to R1’s poor blood flow to the legs. Furthermore, the complainant stated that the physician reported that even if R1 is repositioned every two hours, the discoloration will not go away, due to the fragile skin condition, and poor blood flow to the legs. The complainant added that although R1 has sacral redness, the redness is on the top layer of the skin, skin is not broken, and it is not a pressure wound. The complainant stated that R1 is doing well, ‘looks great’, and no further concerns were noted. LPA Urena interviewed the Administrator on 01/31/2023 at 11:30 a.m. The administrator stated that on 01/26/2023, staff noticed a change in R1’s demeanor; weak and not eating as usual. Consequently, the administrator contacted R1’s primary physician to inform them of the changes noticed by facility staff, and doctor recommended taking R1 to the hospital. R1 was taken to the hospital by facility staff due to R1 not feeling o.k., and experiencing weakness. The LPA conduced record review, and the record review revealed that the staff keeps progress notes on residents. Progress notes for R1 revealed that staff indicated the date that R1 was noted to have a change in condition, taken to hospital, and that staff communicated with R1’s primary physician. R1 was receiving home health services at facility up to 01/16/2023.

Based on the information provided by a credible witness, and record review, the resident did not sustain an injury while in care. Therefore, this allegation is deemed Unsubstantiated at this time.

No citations were issued. Exit interview was conducted with the Administrator. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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