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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610489
Report Date: 04/10/2024
Date Signed: 04/12/2024 09:48:48 AM

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
04/09/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240409084443
FACILITY NAME:VELVET CARE 2FACILITY NUMBER:
197610489
ADMINISTRATOR:PAROYAN, NAIRAFACILITY TYPE:
740
ADDRESS:16909 CITRONIA STREETTELEPHONE:
(310) 480-2009
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Hayk Kirokosyan- LicenseeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Residents bedroom is being used as a passageway to another room.
The garage is used as a living space for staff.
INVESTIGATION FINDINGS:
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On 4.10.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced complaint visit regarding the above allegations. LPA was greeted by Cynthia Sherriel (S1) who is the staff of the facility. At 10:30 AM Hayk Kirokosyan who is the licensee arrived at the facility and explained the reason for the visit. An entrance interview was conducted.

At 10:05 AM LPA conducted a physical plant tour with the assistance of the staff to ensure the health and safety of the residents in care.

Allegation: Residents bedroom is being used as a passageway to another room.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an initial complaint visit. Regarding the allegation above it is alleged that residents bedroom is being used as a passageway to another room (garage). Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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-20240409084443
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: VELVET CARE 2
FACILITY NUMBER: 197610489
VISIT DATE: 04/10/2024
NARRATIVE
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It was alleged that residents bedroom #3 and bedroom #4 was used as a passageway for staff to enter the garage (staff bedroom) or exit the facility. To investigate the complaint, LPA interviewed staff and residents from 10:30-11:30 AM. LPA interviewed four (4) out of four (4) staff and four (4) out of five (5) residents. During the interview for the residents, R2 who resides in bedroom #4 stated that their bedroom is used as a passageway that leads to the garage, which is the staff bedroom. R2 spends most of their time in their bedroom and stated that staff would enter bedroom #3 and bedroom #4 without knocking, look at R2, and just walk by to use the exit door that leads to the garage (staff bedroom) or exiting the facility. R5 is bedridden and advised LPA that their bedroom #3 is used as a passageway to exit the facility. Therefore, this allegation is SUBSTANTIATED.

Allegation: The garage is used as a living space for staff.

It was alleged that the facility used the garage as a staff living space. According to the facility sketch and observation on 12.5.2023, the facility is approve for four (4) bedroom, garage as a storage, kitchen, living room and two (2) bathrooms. To investigate this complaint, during LPA facility tour at 10:05 AM. LPA observed that the garage has an air-conditioning unit, queen mattress with full bed frame, sofa, incontinent supplies, staff belongings, PPE storage and staff refrigerator. Four (4) out of four (4) staff confirmed that the garage is where staff sleeps. Three (3) out of five (5) residents confirmed that the staff lives in the garage. Licensee and staff confirmed that the garage is not permitted for living/sleeping area, it is only for storage. The garage has a male and female staying in the garage room and was later identified as administrator's parents that are hired to be the staff in the facility. Licensee acknowledged that staff do sleep in the garage area. Licensee reported that they will not allow any person(s) to reside in the garage any longer and staff schedule for LIC 500 will be updated. Based upon the findings of the investigation, the above allegation is deemed SUBSTANTIATED at this time.
Following citation is issued for the identified deficiency pursuant to Title 22 regulations.

Exit interview conducted, appeal rights discussed, copy of this report is provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240409084443
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: VELVET CARE 2
FACILITY NUMBER: 197610489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
87307(d)(6)
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Personal Accommodations and Services: The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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Licensee/administrator will submit a written statement notifying the department what steps will be taken to clear this deficiency and to ensure such deficiency will not reoccur.
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This requirement is not met as evidenced by: The staff uses bedroom #4 as a walkway as a pass through that leads to the garage.
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Type B
04/24/2024
Section Cited
CCR
87307(a)
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Personal Accommodations and Services: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may
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Personal belongings needs to be removed and an updated LIC 500 since staff would not be living in facility anymore.
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reside in the facility.
This requirement is not met as evidenced by: Facility used the garage as a staff living space.
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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: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3