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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603127
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:44:20 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
06/22/2022 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20220622091836
FACILITY NAME:ALAMEDA BOARD & CAREFACILITY NUMBER:
198603127
ADMINISTRATOR:AVETISYAN, ARMENUHIFACILITY TYPE:
740
ADDRESS:1129 ALAMEDA AVETELEPHONE:
(213) 595-2777
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY:6CENSUS: 6DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Yelena Amirjanyan, Administrator
Melania Iailoian, Care Provider		TIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Resident is not provided drinking water.
Resident's hygiene needs are not being met.
Facility does not ensure resident is receiving therapy sessions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Alberto Lopez conducted an unannounced site visit to the facility for the purpose of investigating the above complaint allegations. LPA was greeted by Armine Oganesyan DSP, and Administrator Yelena Amirjanyan arrived a short time later.

The investigation consisted of interviews with Administrator and two staff S1-S2, three residents R1-R3. LPA also reviewed and obtained staff rooster, resident roster, R1 Admission Agreement, R1 Physician's report, R1 Hospice Care Inc treatment/medication /DME list. R1 medication list.

Allegation: Resident is not provided drinking water. R1 is under doctor's orders to thicken all liquids including water in order to prevent aspiration. Administrator and 2 of 2 staff stated they provide resident with water but thicken it with “Thick it Powder” according to Doctor’s orders. 3 of 3 residents stated they get water when they ask.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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 4
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
06/22/2022 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20220622091836

FACILITY NAME:ALAMEDA BOARD & CAREFACILITY NUMBER:
198603127
ADMINISTRATOR:AVETISYAN, ARMENUHIFACILITY TYPE:
740
ADDRESS:1129 ALAMEDA AVETELEPHONE:
(213) 595-2777
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY:6CENSUS: DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Yelena Amirjanyan, Administrator
Melania Iailoian, Care Provider		TIME COMPLETED:
03:58 PM
ALLEGATION(S):
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9
Resident is not provided new clothing
INVESTIGATION FINDINGS:
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Allegation: Resident is not provided new clothing.

Administrator stated that she purchased clothing for resident, Administrator stated he came with nothing and she has provided all his clothing. Administrator did not save receipts and stated it was a provided to resident as a gift. LPA observed clothing that belonged to resident including new clothes. However, resident did not have any socks.

Based on the interviews conducted and observations, there was enough supportive evidence to concur with the reported allegation. Therefore, the allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20220622091836
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights

2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

The above was not met by evidence of:
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Licensee will purchase new socks for R1 and will send receipts and photos to LPA by POC date as proof.
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Facility staff could not find resident's socks in his possesion or anywhere in the facility.
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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: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220622091836
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: 06/23/2022
NARRATIVE
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Allegation: Resident's hygiene needs are not being met. Administrator and two staff (S1 -S2) stated that all of resident’s hygiene needs are being met and that resident can communicate when he wants his hygiene needs taken care of. Administrator stated resident is under Hospice care and they provide bathing services 2 times per week.

Facility does not ensure resident is receiving therapy sessions: Administrator stated that there is no doctor order for any kind of therapy, and they do not provide that service.



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Administrator and care provider Melania Iailoian and Administrator gave Care provider authorization to sign report.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4