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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850569
Report Date: 07/31/2025
Date Signed: 07/31/2025 11:29:14 AM

Substantiated


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
03/17/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250317143946
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: 5DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Andranik KapikayanTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff handled resident in a rough manor resulting in multiple bruises
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Staff and explained the reason for the visit. Administrator arrived shortly after.

On 03/17/2025, the Department received a complaint alleging physical abuse of Resident #1 (R1). It was reported that R1 was observed with approximately twenty (20) bruises on different parts of R1’s body. The case was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Douglas.

On 03/19/2025, from 1:50pm to 3:00pm, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA Balisi met with staff and explained the reason for the visit. Administrator Andranik Kapikyan was contacted and stated they could not be onsite for the visit, but staff Jessy Phiri could sign in their place.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 7
Control Number 29-AS-20250317143946
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: 07/31/2025
NARRATIVE
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At approximately 2:05pm, the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. The LPA determined further investigation was needed before delivering the findings.

On 04/10/2025, at approximately 5:20pm, Investigator Douglas conducted interviews with R1’s resident representative; on 05/07/2025, at approximately 3:30pm, with Staff #1 (S1); and on 05/09/2025, at approximately 9:20am, with the Administrator. In addition, Investigator Douglas reviewed Glendora Oaks Behavioral Health Hospital records, Adventist Health Hospital Simi Valley Hospital records, photos, and facility file documents related to R1.

According to the facility file documents reviewed, R1 was admitted to Glendora Oaks Behavioral Health Hospital from 01/31/2025 to 03/07/2025, as an inpatient for a psychiatric disorder. Upon discharge from the hospital, R1 was admitted to the Peaceful Pines Senior Living Corp facility on 03/07/2025.

R1’s Preplacement Appraisal Information, dated 03/05/2025, noted that upon admission to the Peaceful Pines Senior Living Corp facility, R1 had “visible bruising all over body.” R1’s Physical Disabilities were noted as lack of speech and behavioral disturbance. Mental Conditions for R1 were listed as confused, withdrawn, paranoid, and disorientated. The Preplacement Appraisal also noted R1 needed assistance with bathing, haircare and personal hygiene, as well as assistance with toileting.

The review of R1’s Physician Report, dated 03/05/2025, lacked a primary or secondary diagnosis. The report indicated R1 had mild cognitive impairment (MCI), was confused/disoriented and displayed inappropriate behavior. The report noted a history of skin condition or breakdown as “rashes and bruising”. The report also indicated R1 was able to bathe and care for R1’s toileting needs, however, was not able to dress or groom themself. R1’s Resident Appraisal form, dated 03/07/2025, also indicated R1 did not require assistance with bathing or toileting.

Both the Administrator and S1 acknowledged when R1 initially arrived at the facility R1 had bruising on R1’s back which were “black” in color. S1 stated they were not informed as to where R1 sustained the bruising prior to R1’s arrival. The Administrator stated the Glendora Oaks Behavioral Health hospital staff notified him of bruising on R1. The bruising was also noted on R1’s Preplacement Appraisal Information.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20250317143946
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: 07/31/2025
NARRATIVE
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Information obtained during the Department’s interviews revealed that sometime in the first week of R1’s stay at the facility R1 was given a shower by S1. S1 acknowledged S1 was the staff member who showered R1. S1 explained that, although R1 was deemed independent by R1’s doctor and could bathe self, R1 had only taken a total of two showers during the time R1 was at the facility. (R1 resided at the facility from 03/07/2025 to 03/24/2025). S1 explained one day, R1 urinated on self and in bed. However, R1 refused to take a shower. S1 described that day as “hell” because S1 had to physically pull R1 to the shower. S1 stated R1 did not want to change R1’s soiled clothes. S1 acknowledged S1 had to remove R1’s clothes against R1’s will. S1 also acknowledged S1 grabbed R1’s wrists to attempt to escort R1 to the shower. However, that was not effective. S1 stated S1 then used the technique of bringing S1’s arms underneath R1’s armpits from behind grabbing R1’s shoulders and pull R1 to the bathroom. S1 acknowledged that once S1 got R1 in the shower S1 was able to wash R1’s entire body including R1’s vaginal area. S1 stated the entire incident took approximately 10 minutes. S1 acknowledged R1 sustained bruising on R1’s wrists because of S1’s initial grabbing R1 to take R1 to the shower. S1 acknowledged R1’s resident representative arrived at the facility later that day and observed bruising on R1’s arm and requested they no longer give R1 any showers. S1 stated they did not inform the Administrator of the incident.

During the Department’s investigation, it was disclosed that R1 was forcibly given a shower by S1. S1 acknowledged giving R1 a shower after R1 urinated on self in bed and refused to take a shower. S1 also acknowledged causing bruising to R1’s arm and wrist after forcibly grabbing R1 and pulling R1 to the bathroom to bathe R1. Information in R1’s Physician’s Report and Resident Appraisal indicated R1 was able to bathe self, and care for own toileting needs. Photos of R1’s bruises illustrated several dark bruises to R1’s wrist and arm, resembling fingerprint marks. The information obtained during the Department’s investigation provided sufficient evidence to substantiate physical abuse. Therefore, the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20250317143946
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2025
Section Cited
CCR
87468.1(a)(3)
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To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
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Licensee agreed to review section cited with staff and provide a written plan on how they will ensure future compliance with the regulation and provide document to LPA via email by COB 08/01/2025.
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Based on interviews, the licensee did not comply with the section cited above when S1 caused bruising to R1’s arm and wrist after forcibly grabbing R1, which posed an immediate health and safety risk to residents in care.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
03/17/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250317143946

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: 5DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Andranik KapikayanTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
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Staff touched resident inappropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Staff and explained the reason for the visit. Administrator arrived shortly after.

On 03/17/2025, the Department received a complaint alleging sexual abuse of Resident #1 (R1). It was reported that Staff #1 (S1) touched R1 inappropriately by washing R1’s private area without R1’s consent. The case was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Douglas.

On 03/19/2025, from 1:50pm to 3:00pm, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA Balisi met with staff and explained the reason for the visit. Administrator Andranik Kapikyan was contacted and stated they could not be onsite for the visit, but staff Jessy Phiri could sign in their place.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20250317143946
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: 07/31/2025
NARRATIVE
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At approximately 2:05pm, the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. The LPA determined further investigation was needed before delivering the findings.

On 04/10/2025, at approximately 5.20pm, Investigator Douglas conducted interviews with R1’s resident representative; on 05/07/2025, at approximately 3:30pm, with Staff #1 (S1); and on 05/09/2025, at approximately 9:20am, with the Administrator. In addition, Investigator Douglas reviewed Glendora Oaks Behavioral Health Hospital records, Adventist Health Hospital Simi Valley Hospital records, and facility file documents related to R1.

According to the facility file documents reviewed, R1 was admitted to Glendora Oaks Behavioral Health Hospital from 01/31/2025 to 03/07/2025, as an inpatient for a psychiatric disorder. Upon discharge from the hospital, R1 was admitted to the Peaceful Pines Senior Living Corp facility on 03/07/2025.

R1’s Preplacement Appraisal Information, dated 03/05/2025, noted that upon admission to the Peaceful Pines Senior Living Corp facility, R1 had visible bruising all over body. R1’s Physical Disabilities were noted as lack of speech and behavioral disturbance. Mental Conditions for R1 were listed as confused, withdrawn, paranoid, and disorientated. The Preplacement Appraisal Information also noted R1 needed assistance with bathing, haircare and personal hygiene, as well as assistance with toileting.

The review of R1’s Physician Report, dated 03/05/2025, lacked a primary or secondary diagnosis. The report indicated R1 had mild cognitive impairment (MCI), was confused/disoriented and displayed inappropriate behavior. The report noted a history of skin condition or breakdown as “rashes and bruising”. The report also indicated R1 was able to bathe and care for R1’s toileting needs, however, was not able to dress or groom themself. R1’s Resident Appraisal form, dated 03/07/2025, also indicated R1 did not require assistance with bathing and toileting.
Information obtained during the Department’s interviews revealed that sometime in the first week of their stay at the facility, R1 was given a shower by S1. S1 acknowledged S1 was the staff member who showered R1. S1 explained that, although R1 was deemed independent by R1’s doctor and could bathe self, R1 had only taken a total of two showers during the time that R1 was at the facility (R1 resided at the facility from 03/07/2025 to 03/24/2025). S1 explained one day during the first week of their stay at the facility, R1 urinated on self and in bed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20250317143946
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: 07/31/2025
NARRATIVE
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However, R1 refused to take a shower. S1 described that day as “hell” because S1 had to physically pull R1 to the shower. S1 stated R1 did not want to change R1’s soiled clothes. S1 acknowledged S1 had to remove R1’s clothes against R1’s will. S1 acknowledged that once S1 got R1 in the shower S1 was able to wash R1’s entire body including R1’s vaginal area.

During the course of the investigation, it was disclosed that R1 was forcibly given a shower by S1. During the process of S1 giving R1 a shower, S1 washed R1’s vaginal area. However, it was explained by S1 that S1 only gave R1 a shower after R1 urinated on self in bed and refused to take a shower afterwards. R1 reported that S1 forced R1 to shower, and S1 washed R1’s vaginal area without R1’s consent, which made R1 feel uncomfortable. Information in R1’s Physician’s Report and Resident Appraisal indicated R1 was able to bathe self, and care for own toileting needs. The information the Department obtained during the investigation did not sufficiently support the allegation of sexual abuse, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7