Facility Evaluation Report

Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20241014112146). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Staff Zhyparkul Mursamambetova and explained the reason for the visit. LPA contacted Licensee Sarkis Dovlatyan who stated they are unable to make the visit, but stated staff can sign in their place.

During the investigation it was revealed that the facility did not submit a Special Incident Report (SIR) or death report to Community Care Licensing (CCL) to notify that Resident #1 (R1) was admitted to the hospital on 06/18/2024 and R1’s death in the hospital on 06/18/2024, in a timely manner. At approx 9:55 a.m. LPA conducted records review and did not observe any records kept onsite for R1.

A $1,000 immediate civil penalty is assessed today. The staff was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed and copy of report provided.