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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610094
Report Date: 01/13/2022
Date Signed: 01/13/2022 12:36:38 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, 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
01/04/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220104154925
FACILITY NAME:WELLNESS ASSISTED LIVINGFACILITY NUMBER:
197610094
ADMINISTRATOR:MELIKSETYAN, LUSINEFACILITY TYPE:
740
ADDRESS:9115 N WYSTONE AVETELEPHONE:
(747) 218-9141
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 6DATE:
01/13/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Emma Ararutiunian, DesigneeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility has inappropriate locking device on facility door
INVESTIGATION FINDINGS:
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At 10:20am Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above for an initial 10-day complaint visit. Entrance interview conducted with Administrator over the phone. The designee, Emma Ararutiunian arrived at 11:15 am.

Allegation: Facility has inappropriate locking device on facility door

At approximately 11:00 am, LPA conducted a physical plant tour. At 11:15am LPA interviewed caregiver Tamara Ter Grigoryan, who stated the lock had been removed, and she did not know why the lock was removed. LPA interviewed the Administrator over the phone at approximately 10:30am. The Administrator stated the lock had been on the front door for a long time and did not know who or why the lock was placed on the door. The Administrator stated they never use the lock, but a credible source told them to remove the lock, and they removed it.
Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
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 3
Control Number 31-AS-20220104154925
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: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
VISIT DATE: 01/13/2022
NARRATIVE
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 The lock was located on the top right corner of the front door making it inaccessible for residents to reach or release the lock. Upon arrival LPA observed the lock on the front door had been removed. LPA conducted a pre-investigation with an investigator from the Bureau of Fire Prevention & Public Safety, regarding acceptable locks on exit doors. LPA was informed by the investigator an alarm is acceptable, but extra locks are in violation. Therefore, after pre-investigations and interviews with staff, the allegation, “Facility has inappropriate locking device on facility door,” is deemed substantiated.

Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 9099D included with this report.

Appeal rights issued.

Exit interview conducted. Report Delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220104154925
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: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2022
Section Cited
CCR
87307(d)(6)
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87307(d)(6) Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidence by:
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The Administrator has completed the plan of correction, and has removed the lock on the front exit door.
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Based on a credible source and the acknowledgement by the Administrator; There was a lock installed on the top right corner of the front exit door. The lock obstructs the exit should the exit be needed due to an emergency. This is an immediate health and safety risk to all residents in care.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3