<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610645
Report Date: 10/02/2025
Date Signed: 10/02/2025 03:44:27 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
05/22/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250522152714
FACILITY NAME:SONLEMA INCFACILITY NUMBER:
197610645
ADMINISTRATOR:HAKOBYAN, VRAMFACILITY TYPE:
740
ADDRESS:6504 LINDLEY AVENUETELEPHONE:
(818) 747-8172
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 6DATE:
10/02/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:TIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in a resident to sustain pressure injuries while in care.
Staff are not able to properly position a resident while in care.
Staff do not have the appropriate equipment to move a resident.
Staff do not have an appropriate sleeping arrangement for a resident.
Staff do not communicate effectively.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit to this facility. LPA met with staff #1 (S1) Liana Babaian who granted access to the facility. The staff contacted the Administrator via phone and LPA exlained the reason for the visit. The Administrator Designee arrived shortly after. The Administrator had to leave and designated Levon Torsyan (S2) to sign today's report.
An initial complaint visit was conducted on 05/23/2025 and a subsequent visit was conducted on 06/16/2025. At 11:05 AM, LPA requested resident and staff roster. At approximately 11:10 AM, LPA conducted a physical plant tour of the facility. At 11:15 AM, LPA requested documents; however, no documents were provided upon request. Between 11:20 AM – 12:20 PM, LPA interviewed the Administrator Designee, Staff #2 (S2), and one (1) out of one (1) resident. During the subsequent visit on 06/16/25, LPA conducted additonal interviews with the Administrator Designee and staff #2 (S2). During today's visit, LPA conducted an interivew with one (1) out of six (6) residents who were avaliable.
Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
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 5
Control Number 31-AS-20250522152714
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: SONLEMA INC
FACILITY NUMBER: 197610645
VISIT DATE: 10/02/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff neglect resulted in a resident sustaining pressure injuries while in care.
It was alleged that Resident 1 (R1) was observed with untreated wounds on their backside. To investigate this allegation LPA conducted an interview with Administrator Designee and S2 and LPA was informed that R1 was admitted to the facility on 05/15/2025 and hospitalized on 05/20/2025. LPA was informed that the Administrator failed to complete a proper assessment of R1’s condition upon admission to ensure appropriate wound care services were in place. Furthermore, LPA was informed that S2 observed R1 with a wound on R1's backside during R1's stay at the facility. On 05/17/2025, S2 received a call from a Home Health nurse notifying the facility of R1’s wound assessment appointment. LPA reviewed Home Health records and it was confirmed that R1 was assessed by Lifespring Home Health on 05/17/2025 for wound care. R1 received the first documented wound treatment on 05/20/202. Lastly, On 05/30/2025, LPA reviewed hospital medical records, which documented that R1 was evaluated with a Stage II pressure injury on the left gluteal area.

Based on interviews and record reviews, the facility failed to conduct a proper assessment of R1’s wound condition upon admission and failed to ensure consistent wound care services were provided. Therefore, the allegation is Substantiated.


Staff are not able to properly position a resident while in care.

It was alleged that R1 remained in a wheelchair for four (4) days and staff were unable to reposition R1. To investigate this allegation LPA conducted an interview with the Administrator Designee and S2 and both confirmed that staff were unable to move R1 due to R1’s weight (300 lbs.). Furthermore, LPA was informed that the staff only moved R1 for incontinent/diaper changing purposes. Lastly, LPA requested staff training documentation, but the facility was unable to provide evidence of proper training to meet R1’s care needs. Based on interviews and record review, the allegation is Substantiated.

Staff do not have the appropriate equipment to move a resident.

It was alleged R1 was not moved for four (4) days due to lack of personnel and equipment. To investigate this allegation LPA conducted interviews with the Administrator Designee and S2, and both confirmed that the staff were unable to move R1 because the facility did not have a Hoyer lift during R1’s stay from 05/15/2025 to 05/20/2025. Furthermore, R1 was not properly assessed prior to admission, and the Administrator failed to order the necessary equipment in advance. As a result, on 05/20/2025, R1 attempted to stand, fell, and remained on the floor until paramedics arrived. Continue on LIC 9099C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250522152714
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: SONLEMA INC
FACILITY NUMBER: 197610645
VISIT DATE: 10/02/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Lastly, LPA reviewed an invoice of Hoyer lift which was ordered on 05/18/2025 but arrived after R1’s hospitalization. Based on interviews and record review, the allegation is Substantiated.

Staff do not have an appropriate sleeping arrangement for a resident.

It is alleged that R1 was confined to a chair for four (4) days and had difficulty sleeping. It is also reported that R1 only has been in bed for total of three (3) hours over the last four (4) days. To investigate this allegation LPA conducted an interview with the Administrator Designee and S2 and both admitted that R1 did sleep in their wheelchair from 05/17/2025 to 05/20/2025 and only was in their bed for three (3) hours before their hospitalization on 05/20/2025. Furthermore, LPA was informed that due to R1’s weight (300LB) the facility staff were unable to move R1 from and to bed daily; and therefore, R1 decided to remain/sleep in the wheelchair. Both parties interviewed also confirmed that due to the lack of proper assessment the facility also did not have sufficient equipment to provide proper arrangements for sleeping. Therefore, based on interviews this allegation is deemed Substantiated.

Staff do not communicate effectively.

It was alleged that staff members have difficulty communicating with residents due to a language barrier. To investigate this allegation LPA conducted an interview with the Administrator Designee and S2. Both parties interviewed confirmed that Staff #1 (S1) has difficulty communicating in English with residents, the majority of whom speak English. Furthermore, during initial visit on 05/23/2025, LPA conducted an interview with one (1) out of one (1) resident, and during today’s visit LPA conducted an interview with one (1) out of six (6) residents who were available. Interview with residents stated that they have trouble communicating with S1 for basic needs. Lastly, during initial, subsequent, and today’s visit LPA observed that S1 is using a translator application on their phone to communicate with LPA and is unable to communicate in English, and during all visits, LPA also observed that S1 is the only staff available at the facility to provide care and supervision to residents in care. Based on staff and resident interviews, and LPA’s direct observation, the facility failed to ensure effective communication between staff and residents. Therefore, the allegation is Substantiated.

Deficiencies cite and appeal rights explained.


Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250522152714
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: SONLEMA INC
FACILITY NUMBER: 197610645
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2025
Section Cited
CCR
87411(d)(3)
1
2
3
4
5
6
7
87411-Personnel Requirements General-(d)(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.,.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to update LIC 500 with an additional staff (S1 or Administrator) who can communicate effectily in English to meet residents needs at all times. Updated LIC 500 will be submitted to LPA by POC due date.
8
9
10
11
12
13
14
Based on LPA’s interview and observation, the administrator does not have staff available to communicate with residents to provide care which poses a potential risk to the residents in care.
8
9
10
11
12
13
14
Type B
10/09/2025
Section Cited
CCR
87457(a)
1
2
3
4
5
6
7
87457 – Pre-Admission Appraisal
(a) Prior to acceptance of a resident, the licensee shall obtain and evaluate a written medical assessment of the prospective resident to ensure the facility can meet the resident’s needs
1
2
3
4
5
6
7
Administrator will immediately review and revise the pre-admission appraisal process to ensure all medical conditions, including wounds, are accurately assessed before admission. 2. Staff will be trained on wound care protocols,
8
9
10
11
12
13
14
Based on interviews and record reviews the Licensee did not comply with the section cited above by failing to obtain proper pre-admision appraisal prior to R1s admission to the facility which posed a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
including timely referrals, documentation requirements, and monitoring of outside providers’ recommendations. Proof of staff training will be submitted to LPA by POC due date.
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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250522152714
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: SONLEMA INC
FACILITY NUMBER: 197610645
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2025
Section Cited
CCR
87459(a)(4)
1
2
3
4
5
6
7
87459-Functional Capabilities (a)The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform.... :(4) Transferring, including the need for assistance in moving in and out of a bed or chair. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to provide proper equipment (Hoyer lifts, bariatric chairs/beds) to residents prior to admitting them to the facility. 2. Administrator also agreed to provide training to all staff for safe transfer techniques using mechanical lifts
8
9
10
11
12
13
14
Based on interviews and record reviews the Licensee did not comply with the section cited by leaving R1 on a wheelchair for four (4) days without transferring to bed and not providing proper equipment (Hoyer lift) to R1 which poses a potential risk to the residents in care.
8
9
10
11
12
13
14
Proper positioning to prevent falls, and discomfort. Training records will be maintained and submitted to LPA by POC due date.
Type B
10/09/2025
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
87468.2-Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, ...... personal rights:(4) To care, supervision, and services....This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to ensure staff receive immediate training on safe resident positioning, transfers, and the use of assistive devices for residents requiring mobility support. The proof will be submitted to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews and record reviews the Licensee did not comply with the section cited above by leaving R1 in a wheelchair for (4) days without repositing/moving which posed a potential Health, Safety, or Personal Rights risk to persons in care.
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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5