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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610222
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:20:07 PM

Unsubstantiated


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
11/21/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20231121134942
FACILITY NAME:KINGSBURY STREET HOME, INC.FACILITY NUMBER:
197610222
ADMINISTRATOR:SARGSIAN, HARUTFACILITY TYPE:
740
ADDRESS:16457 KINGSBURY STREETTELEPHONE:
(818) 519-8080
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
11/28/2023
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Johnny Sarkisyan, Armine HarutonianTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not ensure resident's health care needs were met
Resident in care is not provided adequate food service
Staff do not ensure the facility is kept at a comfortable temperature for residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Johhny Sarkisyan, and staff, Armine Harutonian, and advised them of the complaint. Today's investigation consisted of interviews with the administrator, staff and residents. LPA also conducted a physical plaint inspection to insure the health and safety of the residents in care, the room temperature is maintained at a comfortable level, and review the supply of perishable and non-perishable food is adequate.

Staff did not ensure resident's health care needs were met:
In regards to the allegation, it was alleged that on or around 11/20/23, Resident 1 (R1) reported to have a high fever and the paramedics would not have been called to assist as the facility staff did not take clients health condition serious. Interviews with the administrator and staff deny the allegation. According to the administrator, and per review of the incident report, that was submitted by the administrator and received
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
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 2
Control Number 31-AS-20231121134942
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: KINGSBURY STREET HOME, INC.
FACILITY NUMBER: 197610222
VISIT DATE: 11/28/2023
NARRATIVE
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on 11/21/23, Staff 1 (S1) observed R1 shaking and having trouble breathing. R1's vitals were checked and oxygen level was low. Paramedics were called for immediate medical attention. R1 was taken to the emergency room and admitted for pneumonia and acute asthma exacerbation. R1 is currently at the hospital, but set for discharge today (11/28/23). Interviews with residents also do not corroborate with the allegation of staff not ensuring the resident's health care needs are not met. No complaints or concerns addressed by the resident regarding their care at the facility. Based on the information obtained, there was insufficient evidence to prove that staff did not ensure resident's health care needs were met. Therefore, the allegation is deemed Unsubstantiated at this time.

Resident in care is not provided adequate food service:
In regards to the allegation, it was reported that R1 requires assistance with having food given to them, but is not getting any help from staff. Interviews with the administrator and staff reveal that R1 is independent, and can feed self. Review of R1's physician's report and admission agreement confirm that R1 is independent, can feed self, and has no additional cost for food service. Interview with residents reveal no complaints or concerns regarding food service. Residents reveal that they are all independent and can feed themselves. Based on the information obtained, there was insufficient evidence to prove that the resident in care is not being provided adequate food service. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff do not ensure the facility is kept at a comfortable temperature for residents in care:
In regards to the allegation, it was reported that the heater in the facility is turned on so high that it is not safe for the residents in the home. Interviews with the administrator and staff deny the allegation. Both stated the temperature is controlled centrally. The thermostat is always set between 71-76 degrees. Thermostat is locked, therefore, no residents have access to adjust. LPA conducted a physical plant inspection to insure the room temperature is maintained at a comfortable level. Currently temperature on the thermostat read at 70 degrees. Interviews with residents reveal no complaints about their rooms, or the home being maintained at an uncomfortable level, or at a temperature so high that it is not safe. Pursuant to title 22, Division 6, Chapter 1, "The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C)." Therefore, based on the information obtained, the allegation of facility staff not keeping a comfortable temperature for residents in care is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2