197610363-9-22-2025-31-AS-NGID-DMVMEH-20251028093242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610363
Report Date: 09/22/2025
Date Signed: 09/22/2025 04:16:56 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
09/15/2025 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20250915193556

FACILITY NAME:	AAA ROYAL SENIOR LIVING FACILITY		FACILITY NUMBER:	197610363
ADMINISTRATOR:	KRISTINA ADMAYAN		FACILITY TYPE:	740
ADDRESS:	6214 BECKFORD AVE		TELEPHONE:	(818) 609-0117
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	09/22/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kristina Admayan, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff mismanaged resident's medication.
Resident did not receive medications as prescribed.

INVESTIGATION FINDINGS:

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At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit. LPA met with the Staff Shushanik Mkrtchyan and the Administrator Kristina Admayan was contacted via telephone. LPA explained the reason for the visit. The Administrator arrived at the facility at 9:45 AM.

During course of the investigation, interviews and record review were made. At 9:50 AM, LPA requested resident and staff roster. At 9:55 AM, LPA conducted and physical plant tour of the facility. At 10:00 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Centrally Stored Medication Record (CSMR), Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. Between 10:15 AM to 12:25 PM, LPA conducted an interview with the Administrator, Staff #1 (S1), and four (4) out of four (4) residents.

Continue on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

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-20250915193556

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: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197610363
	VISIT DATE: 09/22/2025

NARRATIVE

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Staff mismanaged resident's medication.
It was alleged that the facility did give Resident #1 (R1) insulin for three (3) days. To investigate this allegation LPA conducted an interview with the Administrator who denied the allegation and informed LPA that they always provide medication to all the residents in a timely manner without any discrepancy. However, review of R1's Centrally Stored Medication Record (CSMR) revealed that eleven (11) out of eleven (11) prescribed medications have discrepancies and were not provided as prescribed. Furthermore, review of R1's hospital records revealed that R1 was hospitalized from 09/11/2025 through 09/13/2025 due to dizziness for not taking his/her insulin for three (3) days. Additionally, the medical records also revealed that R1 experienced sweating, thirstiness, and polydipsia. LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. Therefore, based on the medication record review, medical records, and interviews this allegation is Substantiated.

Resident did not receive medications as prescribed.
It was alleged that the facility did not have R1's medication at the facility. To investigate this allegation LPA conducted an interview with the Administrator and S1 and both parties interviewed confirmed that R1 currently does not have eight (8) out of eleven (11) prescribed medications due to R1's medical insurance issue. Furthermore, LPA was informed that three (3) out of eleven prescribed medication were also out as of 09/10/2025; however, upon R1's hospitalization R1 was provided three prescribed medication (Divalproex, Lisinopril, and Insuline Aspart) at the hospital. Additionally, LPA reviewed R1's CSMR, and the above information was confirmed that R1's medication run out and the Administrator was unable to refill. Based on interviews and R1's medication review, this allegation is Substantiated.

Deficiencies issued and appeal rights explained.
Exit interview conducted. Copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250915193556

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: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197610363
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/24/2025 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will order the missing medications from the pharmacy and notify doctor regarding the incident. Administrator agreed to schedule vendorized training for all staff by 09/24/25.
	8 9 10 11 12 13 14	Based on medication and hospital record reviews and interviews, licensee did not comply with the section above by not assuring that R1's prescribed medications were delivered timely and administered to R1 as prescribed. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Additionally, Administrator agreed to enroll R1 to HomeHealth services to provide proper insulin intake and injuections.
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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: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC9099 (FAS) - (06/04)

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