197610345-5-9-2025-31-AS-EMIR-DH4SJQ-20250528135529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610345
Report Date: 05/09/2025
Date Signed: 05/09/2025 01:53:42 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
07/22/2024 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20240722130514

FACILITY NAME:	HILDA ASSISTED LIVING		FACILITY NUMBER:	197610345
ADMINISTRATOR:	YEGEYAN, MARY		FACILITY TYPE:	740
ADDRESS:	17179 SAN JOSE STREET		TELEPHONE:	(818) 403-1803
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	05/09/2025
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Nazar "Nick" Yegeyan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not reposition the resident, which led to resident sustaining multiple stage 3 pressure injuries

Staff did not provide adequate food service and ensure for the resident to have drinking water, which resulted in excessive weight loss and malnourishment

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to the facility to conclude the investigation regarding the above allegations. LPA met with the administrator, Nazar "Nick" Yegeyan, and advised him of the complaint. The 10 day visit was made by LPA Cava on 07/23/24. Investigation was then referred to and accepted by Investigation Branch (IB), and assigned to IB Investigator Edward Hector. IB’s investigation consisted of interviews with Administrator, Staff 1 (S1) and Resident 1 (R1). IB also obtained medical records.

On or around June 2024, it was alleged that R1 was sent to the hospital for UTI, where multiple stage 3 pressure injuries were discovered. Treating physician recommended to transfer R1 to a Skilled Nursing Facility (SNF), but R1's responsible person chose to have R1 return to the facility against physician’s advice. On or around July 21, 2024, During a visit to R1 at the facility, additional pressure injuries were observed. Also noted was a foul odor, with blood and pus coming out of the gauze. In addition R1 suffered excessive weight loss and acute organ dysfunction due to a lack of water and high protein food intake.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240722130514

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: HILDA ASSISTED LIVING	FACILITY NUMBER: 197610345
	VISIT DATE: 05/09/2025

NARRATIVE

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IB’s investigation consisted of interviews and record review, and the following revealed:

On June 20, 2024. R1 admitted to hospital and was observed with two stage 3 wounds on lower left leg, an unstageable wound on left upper foot, stage 3 wound on right heel and stage 3 wound on her left knee.
On June 22, 2024, R1 was discharged back to the facility against physician’s advice.
On July 22, 2024, medical records from hospital reveal that R1 was admitted for weakness on July 22, 2024. Moreover, there was evidence of Stage II sacral wounds during physical exam.
On July 23, 2024, R1 was discharged back to the facility.
On or around July 23 or 24, 2024, records from home health reveal that wound care was provided for five wounds. Three stage 3 wounds to R1's right thigh and left leg. One Stage 2 on R1's left knee, and one Unstageable on R1’s sacrum. There were nurse visits on July 23 and 24, 2024.
On November 25, 2024, IB interviewed staff from home health to confirm information from records received. Information from home health via interview and records confirm that R1 had initially six wounds that were Stage 3 as of July 4, 2024. Records also confirmed wound care provided every other day, but then increased to wound care every day. Moreover, there was indication of organ dysfunction, as a possible result from weight loss and malnourishment.

Based on investigation and information obtained by IB, there was enough evidence to corroborate the allegations of R1 sustaining multiple stage 3 pressure injuries and R1 experiencing weight loss and malnourishment. Therefore, the allegations are Substantiated. Citations issued on the 9099D. Administrator advised and a copy of this report issued.

Per California Code of Regulations (CCR), Title 22, an immediate civil penalty of $500 issued today for a violation resulting in R1's pressure injuries. The Licensee is informed that additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49(f) per Departmental analysis.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240722130514

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: HILDA ASSISTED LIVING	FACILITY NUMBER: 197610345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/09/2025 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Prohibited Health Condition: Persons who require health services for or have a health condition including, but not limited to, Stage 3 and 4 pressure injuries, shall not be admitted or retained in a residential care facility for the elderly. This requirement was not met as evidenced by	1 2 3 4 5 6 7	As POC, the administrator will hire a consultant for additional training to address this section of regulation. As proof the POC has been met, copy of training log, training topic and attendance shall be submitted to the Licensing agency by May 23, 2025
	8 9 10 11 12 13 14	medical records received and interviews with home health staff conducted by IB confirming R1 sustaining multiple stage 3 wounds.	8 9 10 11 12 13 14
Request Denied Type A 05/09/2025 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's	1 2 3 4 5 6 7	As POC, the administrator will hire a consultant for additional training to address this section of regulation. As proof the POC has been met, copy of training log, training topic and attendance shall be submitted to the Licensing agency by May 23, 2025
	8 9 10 11 12 13 14	responsible person, if any. This requirement was not met as evidenced by medical records received by IB revealing R1 suffered weight loss and malnourishment.	8 9 10 11 12 13 14

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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

LIC9099 (FAS) - (06/04)

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