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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850569
Report Date: 04/17/2025
Date Signed: 04/17/2025 11:47:35 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250224090712
FACILITY NAME:PEACEFUL PINES SENIOR LIVING CORPFACILITY NUMBER:
565850569
ADMINISTRATOR:KAPIKYAN, ANDRANIKFACILITY TYPE:
740
ADDRESS:321 ROYAL AVETELEPHONE:
(805) 624-8993
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 6DATE:
04/17/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jessy PhiriTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff wrongfully evicted resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. During today’s visit, LPA met with Staff and explained the reason for the visit. Licensee Andranik Kapikyan was contacted and stated they could not be onsite for the visit. Kapikyan stated Staff Jessy Phiri can sign in their place.

On 02/27/2025, the initial complaint visit was conducted by LPA between approximately 02:10 p.m. - 03:00 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that "Staff wrongfully evicted resident" as it was alleged that staff evicted Resident #1 (R1) from the facility. LPA's records review revealed, no eviction notice was ever submitted to the Department for review. R1’s physician’s report dated 01/18/2025, indicated R1 is able to leave facility unassisted and is able to communicate needs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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 2
Control Number 29-AS-20250224090712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEACEFUL PINES SENIOR LIVING CORP
FACILITY NUMBER: 565850569
VISIT DATE: 04/17/2025
NARRATIVE
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Continued from 9099

Additionally, interviews conducted with staff, Administrator and R1 stated no eviction notice was ever provided to R1. On 02/20/2025 at approx. 07:30 p.m. R1 requested assistance from staff to relocate R1's personal belongings to front of the facility as R1 stated they were going to be picked up. R1 did not disclose to the staff who or where they were going. R1 exited the facility with assistance from staff, waited in the driveway then R1 contacted the local police department who arrived at approx. 07:55 p.m. which resulted in R1 returning to the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff wrongfully evicted resident” is deemed Unsubstantiated at this time.
Exit interview conducted and a copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2