Complaint Investigation Report

On 10/22/2025, LPA conducted physical plant tour, interviewed staff and resident with residents and staff while onsite for a separate investigation. On 10/31/2025, from 09:40 a.m. to 01:30 p.m. LPA conducted physical plant tour, interviewed staff and residents while on site for a separate investigation. On 01/16/2026, LPA received and reviewed hospital records for Resident #1 (R1).

It was reported that “Resident sustained unexplained injuries while in care” as it was alleged that Resident #1 (R1) was admitted to a local hospital after bruising and/or red markings were observed on the body. Interviews and a review of available records indicated that on 06/09/2025, a family member visited R1 at the facility and found R1 on the floor. Facility staff were unable to explain the circumstances under which R1 was found on the floor or to identify what actions, if any, were taken following the incident. The family member contacted 911, and R1 was transported to and admitted to a local hospital. Interviews with the Administrator, Lala Soghomonyan, Staff #1 (S1), and the Owner, Sarkis Dovlatyan, indicated that they were not aware of the circumstances that led to R1 being found on the floor. Photographs reviewed at the regional office depicted multiple markings on R1’s arms and face that appeared consistent with bruising. At the time of the site visit, no records for R1 were available for review at the facility. Additionally, interviews and observations conducted during the investigation revealed that Resident #2 (R2) was admitted to a local hospital on 06/27/2025 due to changes in mental status. Upon hospital admission, R2 was assessed and documented as having two wounds: one on a lower extremity and one on the posterior thigh. Based on information gathered during the investigation, the department has sufficient evidence to confirm these allegations occurred Therefore, the allegation that “Resident sustained unexplained injuries while in care”” have been Substantiated at this time.

It was reported that “Staff left resident on floor for an extended period of time” and “Staff did not seek medical attention to resident” as it was alleged that R1 was observed on the floor and staff did not call Emergency Medical Services (EMS). Interviews conducted and records review reflected that on 06/09/2025, a family member visited Resident #1 (R1) at the facility and found R1 on the floor. Facility staff were unable to explain how R1 fell or what actions, if any, were taken after R1 was observed on the floor. The family member contacted 911, and R1 was transported and admitted to a local hospital. Interviews with the Administrator, Lala Soghomonyan, S1, and the Owner, Sarkis Dovlatyan, revealed they did not have knowledge of the circumstances that resulted in R1 being found on the floor. Additionally, during the course of the investigation, it was revealed that Resident #3 (R3) also experienced a fall while in the facility and was not provided with first aid or care in a timely manner. Based on information gathered during the investigation, the department has sufficient evidence to confirm these allegations occurred.