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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609749
Report Date: 04/21/2021
Date Signed: 04/21/2021 01:42:23 PM

Substantiated


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
01/22/2020 and conducted by Evaluator Aja Richardson
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200122101905
FACILITY NAME:ENCINO GARDENSFACILITY NUMBER:
197609749
ADMINISTRATOR:ARUTUNYAN, ALEXFACILITY TYPE:
740
ADDRESS:4930 NOELINE AVETELEPHONE:
(818) 983-5598
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:6CENSUS: 4DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Zoe Gevorkian, StaffTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Staff did not centrally store resident's medication.
Responsible party of resident not notified of fall.
INVESTIGATION FINDINGS:
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10
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13
Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced Subsequent visit regarding the above allegation. LPA met with staff Zoe Gevorkian at 9:45 am. The assistant Administrator Miriam Balasanyan was unable to come to the facility however LPA discussed allegations over the phone. Miriam Balasanyan authorized Zoe Gevorkian to sign the report. LPA explained the reason for the visit.
Allegation: Staff did not centrally store resident's medication. There are concerns that R1’s medications were kept left out in R1’s room. To investigation this allegation LPA Richardson conducted a visit on 1/27/2020 at 12 pm and toured the facility and at 12:30 pm conducted an interview with staff. On 10/1/2020, LPA Richardson conducted interview with R1's home health nurse and on 10/7/2020 at 10:15 LPA interviewed R1’s relative. On today’s visit, 4/21/21, at 10:00 am LPA conducted a facility tour and at 10:30 am, LPA conducted a medication review of all four residents who currently live at the facility. During the facility tour on today’s visit LPA observed
continued on 9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Aja Richardson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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 5
Control Number 31-AS-20200122101905
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: ENCINO GARDENS
FACILITY NUMBER: 197609749
VISIT DATE: 04/21/2021
NARRATIVE
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Resident #2 (R2) medication in room and not being centrally stored. During the medication review LPA was told that staff does not centrally store R2’s medications. During the review of R2’s physician report it stated R2 is unable to manage own medications. Based on LPA interview, observation, and record review this allegation is Substantiated at this time.

Allegation: Responsible party of resident not notified of fall. There are concerns that facility staff did not notify R1’s responsible party about R1’s fall. To investigation this allegation LPA Richardson conducted a visit on 1/27/2020 and at 12 pm LPA RIchardson toured the facility and at 12:30 pm interviewed staff. On 10/1/2020, LPA Richardson conducted interview with R1's home health nurse and on 10/7/2020 at 10:15 am LPA interviewed R1’s relative. On today’s visit 4/21/21, at 10:00 am LPA conducted a facility tour and at 10:30 am, LPA conducted a medication review of all four residents who currently live at the facility. Based on interviews conducted, R1’s family was told by R1 about a fall (unknown date) when R1's relative arrived at the facility. After relative asking staff about the fall staff confirmed that R1 had fallen that day. Based on facility staff not communicating with R1’s family about the fall this allegation is Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code Civil Penalties were assessed during this visit. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. The report was signed, however a copy of the signed report was emailed, along with the appeal rights
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Aja Richardson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2020 and conducted by Evaluator Aja Richardson
COMPLAINT CONTROL NUMBER: 31-AS-20200122101905

FACILITY NAME:ENCINO GARDENSFACILITY NUMBER:
197609749
ADMINISTRATOR:ARUTUNYAN, ALEXFACILITY TYPE:
740
ADDRESS:4930 NOELINE AVETELEPHONE:
(818) 983-5598
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:6CENSUS: 4DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Zoe Gevorkian, StaffTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer resident's medication as instructed by physician.
Resident sustained a fall while in care.
INVESTIGATION FINDINGS:
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** This is an amended report to correct an allegation duplication; no changes to the findings.

Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced Subsequent visit regarding the above allegation. LPA met with staff Zoe Gevorkian at 9:45 am. The assistant Administrator Miriam Balasanyan was unable to come to the facility however LPA discussed allegations over the phone. Miriam Balasanyan authorized Zoe Gevorkian to sign the report. LPA explained the reason for the visit.
Allegation: #1: Staff did not administer resident's medication as instructed by physician. There are concerns that there were days that medications were not given to Resident #1 (R1). To investigation this allegation the LPA conducted a visit on 1/27/2020 and at 12 pm toured the facility and at 12:30 pm interviewed staff. On 10/1/2020, LPA Richardson conducted interview with R1’s home health nurse and on 10/7/2020 at 10:15 LPA interviewed R1’s relative. On today’s visit 4/21/21, at 10:00 am, LPA conducted a facility tour and at 10:30 am, LPA conducted a medication review of all four residents who currently live at the facility. According to interviews conducted there were never any documentation or observation of R1 not receiving medication.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20200122101905
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: ENCINO GARDENS
FACILITY NUMBER: 197609749
VISIT DATE: 04/21/2021
NARRATIVE
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On 1/27/21, when LPA conducted initial visit, the resident had moved out and taken medication and medication list and LPA was unable to review medications. On 4/21/21, LPA Richardson reviewed medications of all the residents currently living at the facility and based on review were given as described. Based on interview and record review there is insufficient evidence that R1 was not given medication as prescribed. This allegation is Unsubstantiated at this time.
Allegation #2: Resident sustained a fall while in care. There are concerns that due to staff neglect that resident sustained falls. To investigation this allegation LPA Richardson conducted a visit on 1/27/2020 at 12 pm toured the facility and at 12:30 pm interview with staff. On 10/1/2020, LPA Richardson conducted interview with R1home health nurse and on 10/7/2020 at 10:15 LPA interviewed R1’s relative. Based on interviews conducted resident fell out of bed and sustained bruising. Facility knew that resident was a fall risk and had fallen before R1 moved into facility. Based on interviews conducted staff immediately came to check R1 and there is insufficient evidence that staff neglect contributed to resident fall. Therefore, this allegation is Unsubstantiated at this time.

The report was signed, however a copy of the signed report was emailed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Aja Richardson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20200122101905
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: ENCINO GARDENS
FACILITY NUMBER: 197609749
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2021
Section Cited
CCR
87465(h)(2)
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87465(h)(2) Incidental Medical and Dental Care: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement was not met as evidenced by:
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1. Staff immediately removed medications.

POC cleared.
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Based on record review of 1 out of 4 resident's medications facility failed to centrally store Resient #2 medications which poses an immediate health and safety risk to residents in care.
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Type B
04/27/2021
Section Cited
CCR
87466
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87466 Observation of Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs....
This requirement was not met as evidenced by:
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 Administrator has agreed to do the following:
1. Administrator will review regulation 87466
2. Train staff on regulation and then submit training topic and signed document with staff that have been trained.
This citation was previously cited on 10/20/20.
Civil Penalty Assessed.
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Based on interviews the facility staff failled to communicate with R1's responsible party regarding R1's change of condition which poses a potential risk to 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Aja Richardson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5