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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610207
Report Date: 09/10/2024
Date Signed: 09/10/2024 07:05:00 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
09/03/2024 and conducted by Evaluator Leizl De La Cerra
COMPLAINT CONTROL NUMBER: 31-AS-20240903145023
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: 1DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH: Administrator, Mariya MelkonyanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident records were not readily available to emergency medical personnel.
INVESTIGATION FINDINGS:
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Licensing Program Analysts LPA Leizl de la Cerra conducted an unannounced visit for the above noted allegation. LPA was greeted with staff caregiver, Mariana and explained the reason for the visit. Facility Administrator/Licensee, Mariya Melkonyan was contacted and arrived shortly.

It was reported that on September 2, 2024, 911 was called, and emergency personnel responded to the above address for a reported resident (R1), who was unresponsive. EMTs and fire technicians arrived on scene and the facility staff #1 (S1) was unable to produce any records regarding R1's demographics, medical history, or medical wishes. During resuscitative efforts, staff did not produce an Advanced Care Directive, (DNR or Power of Attorney). The records were provided by another staff who arrived at the facility after resuscitation effort ended and R1 was determined dead.

CONTINUED to LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
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 3
Control Number 31-AS-20240903145023
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: AMORE VILLA
FACILITY NUMBER: 197610207
VISIT DATE: 09/10/2024
NARRATIVE
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To investigate this complaint, LPA requested copies of facility documents relevant to the investigation at 12pm, records included but not limited to residents’ and staff roster, and R1’s facility file, including but not limited to R1’s identification information, Physician report, advanced directives, DNR, and other records. LPA de la Cerra reviewed the file between 12:30pm and 1:00pm. Staff interviews were initiated between 12:00pm and 12:30pm.

A Review of R1’s resident file revealed that R1 has a signed advance directive, DNR – Do Not Resuscitate, a form previously requested by the emergency personnel. Staff interviews confirmed that S1 did not have R1’s file readily available for emergency personnel.

Based on inspection, observation, interviews and record reviews, there is sufficient information to support the allegation. Therefore, the allegation is substantiated at this time. Per CA Code of Regulations, Title 22 Division 6, Chapter 8, the following deficiency was cited and recorded on LIC9099-D.

During this investigation, LPA noted other Title 22 Deficiencies. Therefore, Case Management visit was conducted in conjunction with complaint investigation to address other deficiencies unrelated to the complaint.



Exit interview was conducted, appeal rights discussed, and a copy of report was issued to facility
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
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 3
Control Number 31-AS-20240903145023
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: AMORE VILLA
FACILITY NUMBER: 197610207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
87469(c)(1)
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87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and... on file experiences a medical emergency, facility staff shall...(1) Immediately telephone911, present the advance directive form to the responding emergency medical personnel & identify the resident as the person to whom the order refers. This requirement is not met as evidenced by,
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Administrator will submit written statement explaining how the facility will follow the implemented policy and procedures on responding to emergency with DNR on file at the facility. Administrator will provide training to ensure cited deficiency does not reoccur. A written statement will need to be submitted to CCL/LPA by POC date.
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Staff failed to immediately provide advanced directive to the responding emergency medical personnel.
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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: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
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)
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