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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609950
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:12:35 AM

Substantiated


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
07/21/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220721154956
FACILITY NAME:PRIME RESIDENTIAL SENIOR CAREFACILITY NUMBER:
197609950
ADMINISTRATOR:KHECHIKYAN, SOFYAFACILITY TYPE:
740
ADDRESS:19418 LANARK STREETTELEPHONE:
(818) 626-8553
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Aikui ZakarianTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff are not following guidelines to prevent the spread of COVID-19
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff who contacted the administrator by telephone. LPA explained the reason for the visit to the administrator.
LPA conducted a physical plant tour from 9:15-9:25am to ensure no immediate health and safety issues. No health and safety issues were noted.
It is alleged that facility staff are not doing a covid-19 screening which include temperature checks on visitors. It is also alleged that staff are not wearing mask while providing care in the facility. Upon entry to the facility staff did not take LPA's temperature or perform a covid-19 screening. During the visit LPA observed home health come to the facility at approximately 9:50am and no covid-19 screening was done. LPA did observe one staff to be wearing a mask while another staff was observed to not be wearing a mask. Based on the information obtained through observation this allegation is deemed Substantiated. Deficiency cited on LIC 9099D. Appeal Rights explained and a copy of report was issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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-20220721154956
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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Administrator shall have an in-service with all staff on Covid Protocols by POC due date. Copy of sign in sheet shall be sent to LPA by email or fax by POC due date.
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Bases on observations facility staff did not ensure the personal rights of persons in care to a safe, healthy, and comfortable home and engaged in conduct inimical to the health, welfare, and safety of persons in care, in that facility staff did not wear a mask, and did not follow COVID-19 guidelines by screening visitors.
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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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
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