197609842-3-14-2025-31-AS-EMIR-DGUTTD-20250520150035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609842
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:54:30 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
08/21/2024 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20240821115956

FACILITY NAME:	SAINT NICK ASSISTED LIVING		FACILITY NUMBER:	197609842
ADMINISTRATOR:	YEGEYAN, MARY		FACILITY TYPE:	740
ADDRESS:	17177 SAN JOSE STREET		TELEPHONE:	(818) 488-9109
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	03/14/2025
		UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Nazar (Nick) Yegeyan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained an unstageable pressure injury while in care
Facility failed to comply with reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. LPA met with the administrator, Nazar (Nick) Yegeyan, and advised him of the allegations. The initial visit was made by LPA Evelin Rios 08/22/24. Today's investigation consisted of interviews with the administrator, staff and residents. A record review and physical plant inspection was also conducted.

Resident sustained an unstageable pressure injury while in care:
In regards to the allegation, it was reported that Resident 1 (R1) a 90 year old resident, sustained an unstageable pressure injury while in the facilities care. On 8/4/24 R1 was brought to the hospital after it was discovered that R1 had an unstageable wound to the sacrum. R1's responsible persons did not know that resident had a wound and trusted the facility with R1's care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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-20240821115956

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: SAINT NICK ASSISTED LIVING	FACILITY NUMBER: 197609842
	VISIT DATE: 03/14/2025

NARRATIVE

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Interview with the administrator and staff deny the allegation of R1 sustaining an unstageable injury. The following information was obtained through interviews and record review:

R1 admitted 03/14/24
Hospice was initiated on or around 03/15/24.
Review of the hospice care plan indicates risk for skin integrity due to immobility & Stage II pressure ulcer. Instructions to turn/reposition every two hours
No indication of pressure injuries greater than a Stage II ulcer.
Interviews made with hospice nurse and record review on 03/14/25 reveal nurse visits two times per week, with a doctor follow up every other week to assess the wound
Interview with hospice nurse and review of care plan from 03/15/24 through 08/02/24 only indicate wound to coccyx to be Stage II pressure injury (no indication of pressure injury greater than Stage II)
Interview with hospice nurse stated next scheduled visit to facility to treat and assess R1's pressure injury would have been 08/05/24, or the following Monday.

According to both administrator and hospice nurse, R1's wound was never more than Stage II while under the care and supervision at the facility. Both were in communication daily regarding the status of the wound. Facility staff continued to reposition R1 every two hours through 08/04/24. Per staff, no indication the wound had progressed.

On 08/04/24, during visitation, there was some indication that R1's wound may have progressed. According to both administrator, and hospice nurse, R1 was sent to the hospital for assessment.

Although there is evidence that R1 had a Stage II pressure injury, Documentation and interviews with hospice nurse reveal that wound care was provided up until the Stage II pressure injury had possibly progressed. Once it was assumed that it progressed, R1 was sent to the hospital for assessment. Therefore, based on the information obtained, it could not be proven that R1 sustained a pressure injury while in care. The allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20240821115956

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: SAINT NICK ASSISTED LIVING	FACILITY NUMBER: 197609842
	VISIT DATE: 03/14/2025

NARRATIVE

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Facility failed to comply with reporting requirements:
In regards to the allegation, it was reported that R1's responsible person did not know that R1 had a wound and trusted the licensee (Board & Care) with R1's care since admission to the facility. Interview with both the administrator and hospice nurse deny the allegation, stating R1's responsible person was aware of the wound care because the responsible person signed off on the hospice care plan, and was made aware of the plan. Moreover, the responsible person is given a copy of the agreement with the hospice agency and care plan. LPA reviewed a copy of R1's hospice agreement, and observed dates and signatures by R1's responsible person, acknowledging hospice care. In addition, according to administrator, R1's responsible person is often at the facility at least once a week, and is given updates regarding R1's care. During those visits, administrator stated R1's responsible person never made any concerns or complaints regarding care and supervision provided to R1.

Based on the information obtained, there wasn't enough information to corroborate the allegation of licensee failing to comply with reporting requirements. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

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