198603601-2-21-2023-28-AS-RORN-CQDL9J-20230329083333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603601
Report Date: 02/21/2023
Date Signed: 02/21/2023 03:25:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
02/16/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230216104319

FACILITY NAME:	GRANT SERENITY OF DEL MAR INC.		FACILITY NUMBER:	198603601
ADMINISTRATOR:	ADJIAN, MARTIN		FACILITY TYPE:	740
ADDRESS:	3049 E. DEL MAR BLVD		TELEPHONE:	(818) 425-6797
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	6	CENSUS: 6	DATE:	02/21/2023
		UNANNOUNCED	TIME BEGAN:	01:21 PM
MET WITH:	Gohar Armani - Caregiver		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility staff are not meeting resident's hygiene needs.

INVESTIGATION FINDINGS:

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Licensing program analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Gohar Armani Caregiver and explained the reason of the visit. Nvard Gevorkian licensee arrived 20 minutes later.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster. LPA interview resident #1(R1), #2(R2), #3(R3), administrator (S1), and staff #2(S2). LPA requested copies of physician's report, emergency and identification information, appraissal/needs and service plan for R1,R2,R3, and shower, diaper change, and repositioning for R1, and resident observation checklist for 2/12/23, 2/16/23, 2/19/23.

The investigation revealed the following: Regarding allegation: Facility staff are not meeting resident's hygiene needs.It is alleged resident was unkempt, genitals were very dirty, skin was irritated, and resident was sitting in own urine. Interviews with residents revealed 3 out of 3 residents stated the facility's staff provide assistance with showers, and changing as needed. As well as the staff ensure residents are clean. (CONTINUED LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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-20230216104319

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY OF DEL MAR INC.	FACILITY NUMBER: 198603601
	VISIT DATE: 02/21/2023

NARRATIVE

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R1 stated that caregivers provide more showers than resident requires.Interview with staff revealed staff provide assistance with showers for the residents 3 times a week. R1 tends to refuse but staff encourage resident to shower. Documents reviewed revealed R1 has bowel and bladder impairment and needs assistance with personal grooming and hygiene care. Appraisal needs and services plan notes R1 needs assistance with toileting and other grooming activities and caregivers are to assist with those. A diaper change log was reviewed for the month of January for R1 which notes R1 was change at least twice a day. One entry was noted for shower on the week of 22nd - 28th of January. Per staff logs for February were not tracked but showers and changing were provided. LPAs observation during the visit LPA observed R1 was clean, no incontinence odor was noticed.

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

Exit interview was conducted with Nvard Gevorkian Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

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