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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610111
Report Date: 11/07/2024
Date Signed: 01/24/2025 09:06:27 AM

Unsubstantiated


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: 5DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Andranik Kapikyan- AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff is buying alcohol for residents.
Personnel qualification to dispense medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Huma Rahimi conducted an subsequent complaint visit to the facility to investigate the above allegations. LPA met with designee staff member (Isiah Phiri) and was advised about the visit. Staff called administrator and Andranik Kapikyan arrived at 10AM; and advised the reason of the visit.

An entrance interview was conducted.

Today's investigation involved interviews with the administrator, staff, and residents. LPA also conducted a physical plant inspection of the facility at 9:40 AM to ensure the health and safety of the residents and a review of records. At 11AM, LPA requested the resident and staff roster. During the investigation, interviews and record reviews 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: 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 3
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: 11/07/2024
NARRATIVE
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At 11AM LPA requested copies of pertinent information which include facility program and training documents relevant to the investigation. Between 10Am-11AM LPA interviewed the administrator, staff, and five (5) out of five (5) residents.

Allegation #1: Staff is buying alcohol for residents.

Administrator and 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 (S2) 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. Administrator and staff indicated that they have not received any complaint about other residents consuming alcohol. Interviews with administrator, staff and residents indicated that alcohol is allowed in the facility and have no concerns. Information revealed that staff did not provide alcohol to clients and staff ensured a safe and healthy environment for clients.

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

Allegation #2: Personnel qualification to dispense medication.

It was alleged that S1 was not comfortable distributing medication to the residents without proper training. Interview with administrator on 11.7.2024 revealed that before on boarding staff, they always need to undergo proper training in order to care and treats residents in care.

Records review reveal current training on file for S1. On 9.10.2024 interview with five (5) out of six (6) residents reveal S1 to be pleasant, informative, professional, and helpful when distributing medication. Based on interviews and record review during this visits there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.



Exit interview conducted. Copy of this report was given to the administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
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 3