<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:32:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/04/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240904133101
FACILITY NAME:CALIFORNIA STATE HEALTH GROUP LLCFACILITY NUMBER:
197610111
ADMINISTRATOR:ANDRANIK KAPIKYANFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 810-9339
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Isaiah Phiri- DesigneeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff sleeping in common room.
Facility is in disrepair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Gina Saucedo conducted an initial complaint visit to the facility to investigate the above allegations. LPA met with designee staff member (S1), Isiah Phiri and was advised about the visit. Administrator was not available; staff called administrator and advised the reason of the visit over the phone.

An entrance interview was conducted.

Today's investigation involved interviews with the staff and residents. LPA conducted a physical plant inspection of the facility at 10 AM to ensure the health and safety of the residents. At 10:10AM, LPA requested the resident and staff roster, reports could not be produce. Administrator and staff was not available to show records to LPA. A case management will be cited. During the investigation staff and residents interviews were made.
Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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 5
Control Number 31-AS-20240904133101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111
VISIT DATE: 09/10/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Between 10:15-10:45 AM LPAs interviewed the staff, and six (6) out of six (6) residents.

Allegation #1: Staff sleeping in common room.

It was alleged that staff are sleeping in the living room common area. To investigate this allegation, at 10 AM, LPAs conducted a physical plant tour. LPAs did not observe any beds in the living room or other common areas, but did saw a couch in the living room. Between 10:15AM-10:45AM, staff and residents interviews were initiated. Interviews from three (3) out of six (6) residents revealed that staff S1 was sleeping in the living room.



Based on observation and interviews, there is sufficient information to support this allegation. Thus, this allegation is deemed SUBSTANTIATED at this time.

Allegation #2: Facility is in disrepair.

Facility is in disrepair. It is being alleged that the tap water in the kitchen is not functioning and the bathroom in the hallway does not have a toilet seat, which could pose a health and wellness hazard. During the interview, it was confirmed that five (5) out of six (6) residents confirmed that they have not proper working tap working in the kitchen. During the interview, it was confirmed that the a toilet seat was not available for a month. During LPAs physical tour tap water in the kitchen was not working. Bathroom toilet seat eventually was available.

Based on observation and interviews, there is sufficient information to support this allegation. Thus, this allegation is deemed SUBSTANTIATED at this time.

Deficiencies were issued and recorded on LIC 9099-D. Exit interview conducted.



Report signed and delivered. Appeal rights delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/04/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240904133101

FACILITY NAME:CALIFORNIA STATE HEALTH GROUP LLCFACILITY NUMBER:
197610111
ADMINISTRATOR:ANDRANIK KAPIKYANFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 810-9339
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Isaiah Phiri- DesigneeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is buying alcohol for residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Gina Saucedo conducted an initial complaint visit to the facility to investigate the above allegations. LPA met with designee staff member (S1), Isiah Phiri and was advised about the visit. Administrator was not available; staff called administrator and advised the reason of the visit over the phone.

An entrance interview was conducted.

Today's investigation involved interviews with the staff and residents. LPA conducted a physical plant inspection of the facility at 10 AM to ensure the health and safety of the residents and a review of records. At 10:10AM, LPA requested the resident and staff roster, but this was not provided. Aadministrator and staff was not available to show records to LPA. A case management will be cited. During the investigation staff and residents interviews were made.
Continue to LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240904133101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111
VISIT DATE: 09/10/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff interviews reveal that this facility is an Residential Care Facility for the Elderly (RCFE) and residents are allowed to go out in the community by themselves. It was alleged that staff (S1) would purchase alcohol for residents in care at the facility. During the interview it was revealed that staff always make sure that this is a safe and healthy environment for all clients, and drinking would be in moderation. Interviews with residents indicated that alcohol is allowed in the facility and other residents have not seen staff purchasing alcohol for the residents. Information revealed that staff did not provide alcohol to clients and staff ensured a safe and healthy environment for clients. No alcohol was seen at the facility.

Based on observation and interviews, there is insufficient information to support this allegation. Thus, this allegation is deemed UNSUBSTANTIATED at this time.


Exit interview conducted. Copy of this report is given to designee.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240904133101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2024
Section Cited
CCR
87307(a)
1
2
3
4
5
6
7
Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may
1
2
3
4
5
6
7
Staff should not be sleeping in the living room. Administrator will write LPA a letter and email to RO understanding this issue in order to be resolved.
8
9
10
11
12
13
14
 reside in the facility. This requirement is not met as evidenced by: Based on LPAs interview that staff was sleeping in the living room couch. This poses a potential health, safety risk and personal rights violation to residents in care.
8
9
10
11
12
13
14
Type A
09/17/2024
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees
1
2
3
4
5
6
7
Administrator needs to fix tap water faucet in the kitchen to have clean drinking water by 9.17.2024.
8
9
10
11
12
13
14
and visitors. This requirement is not met as evidenced by: Based on LPAs observation that the facility tap worker was not working. This poses a potential health, safety risk and personal rights violation to residents in care.
8
9
10
11
12
13
14
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: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5