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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609950
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:56:17 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
06/23/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230623141817
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: 6DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sofya KhechikyanTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not keep resident(s) free from punishment, humiliation, intimidation, abuse or other acts of a punitive nature.
Staff was negligent while assisting resident(s) while transferring to/from bed
Staff did not provide adequate required incontinent care to resident(s).
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/30/2023 at 9:45 a.m. Licensing Program Analyst (LPA) Evelin Rios made an unannounced 10-day complaint visit to this facility to investigate the above allegations. LPA Rios met with facility administrator Sofya Khechikyan and an entrance interview was conducted, the purpose of this visit was explained.

At approximately 10:00 a.m. LPA and Administrator Sofya toured the physical plant of the facility. LPA did not observe any health and safety issues at this time. From 10:41 a.m. to 11:25 a.m. LPA conducted interviews with residents and staff including the Administrator. At 11:25 a.m. LPA requested records for current residents and previous residents from the last year. Records review revealed resident in question/resident #1 (R1) does not and did not reside at this facility. Interview with the administrator revealed they have never admitted R1 to this facility. At 12:25 p.m. LPA contacted family member of R1 and determined R1 was residing at a different facility.
(LIC9099-C Continued on to next Page)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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-20230623141817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
VISIT DATE: 06/30/2023
NARRATIVE
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5
6
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8
9
10
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13
14
15
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18
19
20
21
22
23
24
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26
27
28
29
30
31
32
(LIC9099-C Continued)

Additionally Sofya provided LIC500, LIC9020. LIC9020 Register Of Facility Clients/Residents and resident records corroborates that R1 does not reside at this facility or has ever resided at this facility. Furthermore, an LIC500 confirms that the staff in question, does not work at this facility.

Based upon the information obtained, this agency has investigated Allegation #1: Staff did not keep resident(s) free from punishment, humiliation, intimidation, abuse or other acts of a punitive nature,
Allegation #2: Staff was negligent while assisting resident(s) while transferring to/from bed and Allegation 33: Staff did not provide adequate required incontinent care to resident(s). We have found that the complaint was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Therefore, the allegation will be deemed UNFOUNDED at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2