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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610207
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:14:38 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
12/20/2022 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20221220142848
FACILITY NAME:AMORE VILLAFACILITY NUMBER:
197610207
ADMINISTRATOR:MELKONYAN, MARIYAFACILITY TYPE:
740
ADDRESS:8455 SPRINGFORD DRTELEPHONE:
(818) 425-4975
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:6CENSUS: 2DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Asya AkopyanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff left resident in the home unsupervised
Staff did not provide a safe environment for residents in care
Staff did not ensure that medications were inaccessible to residents in care
Food is not adequately stored by staff
INVESTIGATION FINDINGS:
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At approximately 12:30 p.m. on 12/28/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out. No immediate health or safety concerns were observed.

LPA conducted a preinvestigation interview at approximately 9:40 a.m. on 12/28/2022 and a file and photo review at approximately 9:55 a.m. LPA conducted a record review at approximately 1:15 p.m.
Regarding the allegation “Staff left resident in the home unsupervised”, it was alleged the facility staff were not present to supervise Resident #1 (R1). A credible source visited the facility on 12/15/2022 and saw no staff present to provide supervision for at least 20 minutes. Based on interviews, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. A $500 immediate civil penalty is assessed today for an absence of supervision for R1. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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 5
Control Number 31-AS-20221220142848
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: AMORE VILLA
FACILITY NUMBER: 197610207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by:
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Licensee will conduct an in-sevice training for all staff on the cited section by the POC due date.
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1 staff which poses an immediate Health, Safety or Personal Rights risk to persons in care.
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Type A
12/30/2022
Section Cited
CCR
87705(f)(2)
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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met as evidenced by:
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Licensee will conduct an in-sevice training for all staff on the cited section by the POC due date. The medication and chemical cleaner cabinets were locked during today's visit.
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Based on photo review, the licensee did not comply with the section cited above in 2 out of 2 cabinets which poses an immediate Health, Safety or Personal Rights risk to persons 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: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20221220142848
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: AMORE VILLA
FACILITY NUMBER: 197610207
VISIT DATE: 12/28/2022
NARRATIVE
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Regarding the allegation “Staff did not provide a safe environment for residents in care”, it was alleged a room contained multiple tripping hazards and a lighter and cleaning supplies was left accessible. A credible source visited the facility on 12/15/2022 and photographed a cluttered room, a lighter left out on a counter top, and cleaning supplies which were unlocked and accessible. Based on photo review and interviews, the allegation is deemed SUBSTANTIATED at this time. Deficiencies are cited on LIC 9099-D.

Regarding the allegation “Staff did not ensure that medications were inaccessible to residents in care”, it was alleged that the medication cabinet was unlocked and medications were accessible. A credible source visited the facility on 12/15/2022 and photographed two unlocked medication cabinets with multiple medications accessible. Based on photo review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D.

Regarding the allegation “Food is not adequately stored by staff”, it was alleged food was improperly stored in the refrigerator. A credible source visited the facility on 12/15/2022 and photographed the inside of the facility refrigerator. Perishable food was stored uncovered at the top of the fridge. Based on photo review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D.

Pursuant to the California Code of Regulations, Title 22, the following deficiencies were observed and cited during the visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20221220142848
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: AMORE VILLA
FACILITY NUMBER: 197610207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
87705(f)(1)
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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement was not met as evidenced by:
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Licensee will conduct an in-sevice training for all staff on the cited section by the POC due date. The cabinet was locked during today's visit.
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Based on photo review, the licensee did not comply with the section cited above in 1 out of 1 lighter which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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CCR
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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: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20221220142848
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: AMORE VILLA
FACILITY NUMBER: 197610207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2023
Section Cited
CCR
87555(b)(9)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
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Licensee will conduct an in-sevice training for all staff on the cited section by the POC due date. All food was properly stored during today's visit.
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Based on photo review, the licensee did not comply with the section cited above in 1 out of 1 food items which poses a potential Health, Safety, or Personal Rights risk to persons 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: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5