197609749-6-22-2021-31-AS-NGID-CN8VSQ-20230119154151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609749
Report Date: 06/22/2021
Date Signed: 06/22/2021 01:31:33 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2021 and conducted by Evaluator Patrick Shanahan

COMPLAINT CONTROL NUMBER: 31-AS-20210617161207

FACILITY NAME:	ENCINO GARDENS		FACILITY NUMBER:	197609749
ADMINISTRATOR:	ARUTUNYAN, ALEX		FACILITY TYPE:	740
ADDRESS:	4930 NOELINE AVE		TELEPHONE:	(818) 983-5598
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 5	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Mariam Balasanyan		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff hit resident with a wheelchair
Staff did not assist resident with their oxygen administration
Staff did not assist resident with their commode
Staff did not assist resident with their bedding
Staff did not administer medication to resident in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Patrick Shanahan, Angela Panushkina, and Melissa Ruiz arrived at the facility in response to the above mentioned allegations. LPAs were greeted by facility staff and explained the reason for the visit. The administrator arrived a short while after.

Allegation 1. Staff hit resident with a wheel chair
LPA's began touring the facility at about 8:45am. At 9:00am, LPA's began interviewing staff and residents regarding this allegation. While interviewing the resident in question (R1) at 9:15am, R1 informed the LPA's that R1 did not believe that the staff intentionally hit R1 with the wheelchair. The staff member in question denied ever being in R1's room, during a phone interview conducted at 10:30 am. All other residents denied ever seeing staff hit any resident with anything.
Based on information received through interviews with staff and residents, this allegation is deemed unsubstantiated.
Continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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 2

Control Number 31-AS-20210617161207

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENCINO GARDENS	FACILITY NUMBER: 197609749
	VISIT DATE: 06/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation 2..Staff did not assist resident with their oxygen administration
LPA's began touring the facility at about 8:45am. At 9:00am, LPA's began interviewing staff and residents regarding this allegation. While interviewing the resident in question (R1) at 9:15am, R1 informed the LPA's that staff assist in changing the oxygen tanks in R1's room. R1, stated that R1 is able to put the breathing tubes on independently and staff do hand the tubes to R1. Staff interviews also confirmed that R1 can take the breathing tubes on and of independently and that the only assistance needed is changing the tanks.
Based on information received from interviews conducted with staff and residents, this allegation is deemed Unsubstantiated.

Allegation 3. Staff did not assist resident with their commode
LPA's began interviewing residents in regards to this allegation at about 9:00 am. 2 out of the 5 residents confirmed that they do use a commode in their rooms at night. All residents interviewed confirmed that staff clean and assist residents to the commode. All other residents confirmed that staff will assist them to the restrooms when needed.
Based on interviews with residents, this allegation is deemed to be unsubstantiated.

Allegation 4. Staff did not assist resident with their bedding
LPA's began interviewing residents in regards to this allegation. LPA's were able to interview 5 out 5 residents in care at the facility, starting at 9:00am. All residents confirmed that staff change the bedding on all beds at least twice, weekly. If bedding becomes soiled, residents confirmed that the bedding will also be cleaned and changed.
Based on interviews with residents, this allegation is deemed to be Unsubstantiated.

Allegation 5. Staff did not administer medication to resident in a timely manner.
LPAs were able to request specific medical documentation at 11;40am, in regard to this allegation. At 1:00PM, LPA's conducted a random medicine count for R1 and all medications were accounted for. R1 is also able to administer R1's prescription medications and PRN medications per R1's most recent Physician report. All residents interviewed stated that they receive their medication on time and have not had any issues regarding receiving their medication.
Based on resident interviews and record review, this allegation is deemed unsubstantiated.

Exit interview conducted and report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2