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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610094
Report Date: 11/07/2024
Date Signed: 11/07/2024 05:00:00 PM

Substantiated


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
10/29/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20241029134703
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: 5DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ruzanna ManukyanTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are unable to effectively communicate with a resident in care.
Staff did not meet the minimum qualifications to provide direct service to resident(s)
Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licesing Program Analyst (LPA) Mariana Agban arrived at the above facility to conduct intitial complaint visit. Upon entrace LPA was greeted by Staff #1 (S1). Adminstator was contacted and the reason for the visit was explained. LPA was informed that the Administor wasn't able to come to the facility and designated Staff 3 (S3) to sign for the report. LPA requested copies of LIC 500 and Resident Roster. LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations.

Allegation: Staff are unable to effectively communicate with a resident in care.
It was alleged that the facility staff was unable to communicate with emergency responders due to language barrier. Interview with S3 confirmed that staff has a communication barrier, however, staff can meet residents' basic needs. S3 stated that on 10/18/24 staff had reported to the Administrator that Resident 1 (R1) was unresponsive and Administrator had called the paramedics. On today's visit, LPA attempted to interview Staff 1(S1) and Staff 2 (S2) but they stated that they don't understand very well English
(Continue on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 4
Control Number 31-AS-20241029134703
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: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
VISIT DATE: 11/07/2024
NARRATIVE
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S1 had asked LPA to use a translation service through S1's phone to translate questions into Russian. LPA attempted interview five out of five residents. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not meet the minimum qualifications to provide direct service to resident(s)
It was alleged that staff didn't know R1's medical history, normal mental status, POA, or resuscitation wishes. Administrator denied the allegation. LPA conducted file review and observed that S1 and S2 didn't meet the minimum qualifications to provide direct services to residents. There were no indications of S2 in-service training. S2 was unable to tell residents names and had to ask S1. Although S1 had in-service training, S1 was unknowledgeable to provide any medical information regarding R1 and other residents. Interview with Administrator revealed that S1 and S2 had no previous related experience to the job as caregivers. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not seek medical attention in a timely manner
It was alleged that staff did not seek medical attention in a timely manner. Administrator denied the allegation. Administrator stated that staff had reported that R1 was unresponsive and thus 911 was called by the Administrator. Moreover, Administrator stated that R1 had been unresponsive a couple of times since their admission to the facility. Interview with Administrator revealed that they are not fully aware of R1's medical condition. Based on information obtained the allegation is deemed Substantiated at this time.

Exit interview conducted, citations issued, appeal rights given copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20241029134703
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: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/28/2024
Section Cited
CCR
87411(d)(3)
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87411-Personnel Requirements - General-(d)(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.,.This requirement is not met as evidenced by:
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Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.
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Based on interviwes staff was unable to communicate with LPA, Staff was using translation device. This poses a potential risk to the residents in care.
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Request Denied
Type B
11/28/2024
Section Cited
CCR
87411(d)(5)
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87411-Personnel Requirements - General-(d)(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help
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Administrator will conducted training to address this section of the regulation. Attendace sheet will submitted to the LPA by the POC date.
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Based on interviwes staff were unable to recoginze ealrly signs of illness which led R1 to hospitalization.
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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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20241029134703
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: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/08/2024
Section Cited
CCR
87464(f)(1)
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Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement has not been met as evidenced by
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Licensee will submit a written plan stating how the facility will ensure that all residents in care are provided with adequate care and supervision to ensure their safety and their needs are being met. Plan to be submitted to CCL by the POC due date
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The licensee failed to ensure staff provided adequate observation regarding R1’s change in condition, and adequate records pertaining to R1’s health and care which led to R1’s hospitalization. This poses as an immediate health and safety risk to the resident in care.
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Type B
11/28/2024
Section Cited
CCR
87411(d)
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87411-Personnel Requirements (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This requirement has not been met as evidenced by:
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Administrator will conduct training for S2 and submit attendance sheet by the POC date.
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Based on records review S2 doesn't have in service training. This poses a potential risk to the 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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4