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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610123
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:18:32 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
11/03/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20211103164432
FACILITY NAME:CONCORDIA ASSISTED LIVINGFACILITY NUMBER:
197610123
ADMINISTRATOR:YEGEYAN, NAZARFACILITY TYPE:
740
ADDRESS:16704 BLACKHAWK STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
11/08/2021
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Nazar Yegyan/ AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility did not issue resident a refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegation. LPA was greeted by facility staff and the administrator was called. LPA began touring the home at about 11:10 AM. No health and safety issues were observed during the visit and the home is following their approved mitigation plan.

Allegation 1 - Facility did not issue resident a refund
LPA was able to interview the administrator at about 11:35 AM regarding this allegation. At 11:45 AM the administrator stated that he knew what this was regarding and went to his car. The administrator provided an envelope with the resident in question's address written on it. The administrator then opened the letter and confirmed that he had written the payment, but due to his family members becoming ill, he never had the chance to mail the letter. A review of the residents rental agreement was conducted at 12:00pm.

Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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-20211103164432
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: CONCORDIA ASSISTED LIVING
FACILITY NUMBER: 197610123
VISIT DATE: 11/08/2021
NARRATIVE
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According the the signed rental agreement, "Fees paid in advance will be refunded within 15 days of removal of a deceased residents belongings." The resident in question passed away on 7/10/21 and all personal belongings were moved out by 7/13/21. The administrator did not deny the timeline and confirmed that the refund was written but a family member became ill and the administrator forgot to issue the payment.
Based on interviews and a review of the admission agreement, this allegation is deemed SUBSTANTIATED at this time.

Exit interview conducted, deficiencies cited and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211103164432
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: CONCORDIA ASSISTED LIVING
FACILITY NUMBER: 197610123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited
HSC
1569.652(c)
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Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually
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Administrator put the payment in the mail during LPA's visit. This was cleared during the visit.
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responsible for the fees ... within 15 days after the personal property is removed.
This requirement is not met as evidenced by:
Based on record review & interview, licensee did not issue a refund within 15 days of R1's personal property being removed which posed a potential personal rights risk to 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: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3