198603127-5-24-2021-28-AS-MVAO-C48UTW-20210622155236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603127
Report Date: 05/24/2021
Date Signed: 05/24/2021 04:45:08 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20200722144114

FACILITY NAME:	ALAMEDA BOARD & CARE		FACILITY NUMBER:	198603127
ADMINISTRATOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	1129 ALAMEDA AVE		TELEPHONE:	(213) 595-2777
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91201
CAPACITY:	6	CENSUS: 5	DATE:	05/24/2021
		UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Yelena Amirjanyan - Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care
Facility staff is not ensuring that resident eats an adequate amount of food
Facility staff did not dispense medication as prescribed
Facility staff are not assisting resident with transfers
Facility staff are isolating resident

INVESTIGATION FINDINGS:

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This is a corrected version of report dated 5/6/21 to clarify the number of ambulatory and non-ambulatory residents.

On 5/6/21 Licensing Program Analyst (LPA) Mary Flores initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Yelena Amirjnayna, the facility administrator.

The investigation consisted of the following: On 7/27/20 LPA Flores conducted telephone interviews with the administrator, residents #1,#2,#3 (R1,R2,R3), staff #2 (S2), and a video call which consisted of a review of food supply, physical plant; 3 resident bedrooms, 3 bathrooms, common areas, reviewed medication and requested copies of Physician's Report, Admissions Agreement, Emergency Identification Information, Needs and Care Plan, Hospice Documents/Notes, Home Health Care Notes, Unusual Incident Reports, Caregiver Notes, Prescriptions for Medication as Needed for R3. On 2/27/21 LPA ineterview resident's family member. On 4/7/21 LPA requested Medication Sheets and Facility's menu. (CONTINUED LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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 28-AS-20200722144114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALAMEDA BOARD & CARE	FACILITY NUMBER: 198603127
	VISIT DATE: 05/24/2021

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident sustained unexplained injuries while in care. It is alleged resident has bruises and open sores on resident's legs. During facility's tour LPA observed 2 non-ambulatory and 1 ambulatory residents in care. Interviews with 2 out of 3 residents stated caregiver assist with everything and 1 out of 3 residents was unable to answer due to cognitive skills. Interview with administrator/caregiver stated to follow plan of care for the residents and that 1 resident is receiving Hospice care and currently receiving wound care, per regulations a facility can retain a resident with injuries if resident is receiving services from a Hospice agency or Home Health Care. Documents review determined 1 out of 3 residents is receiving Hospice care provided Monday through Friday including wound care. Based on LPA's interviews and documents review conducted the preponderance of evidence standard has been met. Therefore the above allegation(s) are found UNSUBSTANTIATED.

Regarding allegation: Facility staff is not ensuring that resident eats an adequate amount of food. It is alleged that resident is not eating. During interviews with 2 out 3 stated to receive 3 meals a day and "all the food I like" and 1 out of 3 residents was unable to answer due to cognitive skills. Interview with administrator revealed facility provides 3 meals a day and 2 snacks. During facility's tour LPA observed sufficient food; 2 days of perishables and 7 days of non-perishables for 3 residents. Document review of food options revealed facility provides different food options that include protein, grains or starch, vegetables, dairy, and fruits or juice daily. Based on LPA's interviews, observation, and documents review conducted the preponderance of evidence standard has been met. Therefore the above allegation(s) are found UNSUBSTANTIATED.

Regarding allegation: Facility staff did not dispense medication as prescribed. It is alleged resident is being given medicines for no reason. During interviews with 2 out of 3 residents it was revealed residents receive medication based on their prescription. 1 out of 3 residents was unable to answer due to cognitive skills. Interview with administrator revealed medication is provided to the residents by the administrator and follows the prescription orders. Documents reviewed revealed 3 out of 3 residents have been prescribed medication by a physician and a centrally store medication sheet is kept at the facility. Facility training/in service were provided on 1/5/20 Topic: Dementia/Medication and on 7/7/20 Topic: Medication Rights to facility's staff. Based on LPA's interviews and documents review conducted the preponderance of evidence standard has been met. Therefore the above allegation(s) are found UNSUBSTANTIATED.

(CONTINUED LIC9099C)

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200722144114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALAMEDA BOARD & CARE	FACILITY NUMBER: 198603127
	VISIT DATE: 05/24/2021

NARRATIVE

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Regarding allegation: Facility staff are not assisting resident with transfers. It is alleged staff leave resident in bed all day. During facility's tour LPA observed 2 ambulatory and 1 ambulatory residents in care. Interviews with 1 out of 3 residents stated caregiver assist with transferring from bed to wheel chair, however resident stated "I don't leave my bed", resident chooses to stay in bed. 1 out of 3 residents stated not to required assistance to transfer, and 1 out of 3 residents was unable to answer due to cognitive skills. During interview with administrator/caregiver it was revealed 1 resident is under hospice and when assisted to wheelchair, resident requests to stay in bed. Based on LPA's interviews and documents review conducted the preponderance of evidence standard has been met. Therefore the above allegation(s) are found UNSUBSTANTIATED.

Regarding allegation: Facility staff are isolating resident. It is alleged resident's room has no windows and resident has been isolated since arriving at the facility. During facility's tour LPA observed 3 residents bedrooms and each room had a large window which is operable. LPA observed ambulatory residents in different areas of the home. Interviews with 1 out of 3 residents revealed resident choose to be in bed and bedroom, and caregivers provide care and meals for resident. 1 out of 3 residents stated caregiver assists with everything resident needs and 1 out 3 residents was unable to provide an answer due to cognitive skills. Interview with administrator/caregiver revealed staff allows visitors and follows visitation protocol due to current situation surrounding COVID 19 and staff performs ADLs every two hours for residents.

Based on LPA's observation, interviews, and documents review conducted the preponderance of evidence standard has been met. Therefore the above allegation(s) are found UNSUBSTANTIATED.

Exit interview was conducted with Yelena Amirjanyan - administrator, and a copy of the report was email for signature.

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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