195850227-5-28-2026-29-AS-KLOZ-DUK3EE-20260529181101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850227
Report Date: 05/28/2026
Date Signed: 05/28/2026 02:37:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/30/2025 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20250430153711

FACILITY NAME:	AMERIHOME, INC		FACILITY NUMBER:	195850227
ADMINISTRATOR:	SARGSYAN, JASMINE H		FACILITY TYPE:	740
ADDRESS:	17019 MARLIN PL		TELEPHONE:	(818) 441-3590
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 5	DATE:	05/28/2026
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Jasmine Sargyan		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff did not prevent resident from developing multiple pressure injuries while in care.
Resident sustained an unexplained injury while in care.

INVESTIGATION FINDINGS:

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On 05/28/2026, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to deliver findings for the allegations listed above. The LPA was greeted by staff and the staff contacted the Administrator on the phone. The LPA spoke with the Administrator on the phone, and explained the reason for the visit. The Administartor stated they were away at an appointment, and agreed to have the report over the phone.

On 04/30/2025, the CCL department received a complaint about the allegations listed above. On 05/01/2025, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility and made an unannounced visit to investigate the allegations listed above. LPA Urena interviewed the Administrator, the staff, and residents and requested records relevant to the investigation. On 05/18/2026, the LPA conducted an interview with the Home Health nurse.
Continues on LIC 9099C...2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

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 29-AS-20250430153711

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERIHOME, INC	FACILITY NUMBER: 195850227
	VISIT DATE: 05/28/2026

NARRATIVE

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2.Staff did not prevent resident from developing multiple pressure injuries while in care.
It is alleged that the resident (R1) developed unstageable pressure injuries on their mid back, left heal, scapula, right thigh sacral area, and a deep tissue injury on the right heel while residing at the facility. LPA Urena interviewed the R1’s Representative (R), and the interview revealed that R1 had a pressure wound above the coccyx area when R1 was admitted to the facility. R reported that R1 stopped eating and drinking before December 2024 and had lost weight but did not say how much weight. R was dissatisfied with the care facility staff were providing to R1 such as not brushing R1’s teeth, not celebrating “anything”, not allowing them to see when facility staff changed R1’s diapers. Furthermore, the R reported that R1 was receiving Home Health services for the pressure wound. No other reports of pressure injuries were reported by the R during the interview.

Interview with the Administrator revealed that R1 was admitted to the facility on 07/31/2024 with significant skin integrity issues and a history of skin breakdown. The facility immediately implemented frequent incontinence care, repositioning, hygiene assistance, and monitoring, while Home Health (HH) services were involved for wound assessment and ongoing care starting on 08/01/2024. The HH nurse visited the facility twice daily to monitor R1’s medical condition, perform body assessments, monitor skin integrity, and provide wound care follow-up and recommendations to facility staff. Interview with staff revealed that they were following HH nurse’s instructions on how to care for R1’s skin, by repositioning R1 in bed and using supporting pillows. Interview with the HH nurse revealed that R1 was admitted to the facility on 07/31/2024 with pressure wounds at Stage1 and Stage 2, and HH began proving services to R1 at the facility on 08/01/2024. Per HH nurse, facility staff followed all instructions for wound care, observed that the wound dressings were always clean, and observed staff to be caring when taking care of R1. HH nurse reported that R1 was hospitalized in September of 2024 for a UTI, and when R1 returned to the facility, R1’s skin breakdown was in worse condition. Furthermore, HH nurse reported that R1’s wound condition would fluctuate due to being bedbound. HH continued services for R1 until 02/03/2025, when R1 was admitted to the hospital.

Continues on LIC 9099C...3

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250430153711

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERIHOME, INC	FACILITY NUMBER: 195850227
	VISIT DATE: 05/28/2026

NARRATIVE

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3. LPA Urena conducted record review of documents pertaining to the investigation:
Record review of Valley Village Care Center (VVCC), indicated that R1 was admitted to the VVCC on 02/05/2024 and discharged on 07/31/2024. On date of discharge, R1 was weighing 112.0 lbs.
Record review of the Physician’s Report dated 02/07/2024 listed as Primary Diagnosis: Metabolic Encephalopathy, and secondary diagnosis as hand stiffness, dysphasia, ESBL resistance, anemia, COPD, dementia, depression and sleep disorder.
Record review of Distinctive Home Health (DHH) records dated 07/31/2024 indicated that DHH conducted a full assessment of R1. The DHH care plan indicated a certification period of: 08/01/2024 to 09/29/2024. Active Diagnosis: Type 2 Diabetes mellitus with other skin complications; Hypertensive heart disease, Pressure ulcer of Buttock, Stage 2.; Pressure ulcer of Right buttock, Stage 1., Alzheimer's disease. Wound Care: Pressure ulcer of buttock, Stage 2., Pressure ulcer of Right buttock, Stage 1. Multiple scattered redness on bilateral buttocks areas. The patient has multiple skin issues/impairment during skin assessment. Record review of Care Plans dated 2/01/2025, 02/02/2025, and 02/03/2025, indicated that R1 was receiving wound care for two pressure wounds.
Wound #1- Location: coccyx; Status-open; Onset Date: 02/01/2025, Type: Pressure Injury, Stage 3; Length: I cm.; Width: 0.8cm; Depth 0.2 cm. Drainage: None, Odor: None Wound #2- Location: lower back; Status-Open, Onset Date: 02/01/2025, Type: Pressure Injury, Stage 3; Length: 1cm, Width: 1cm; depth: 0.1 cm. Drainage: None Odor: None
Record review of medical records from Northridge Hospital dated 09/14/2024, indicated that R1 was admitted to the hospital for UTI. R1 was given a physical examination, and the following areas were observed: Abdomen-soft, nondistended; Extremities-no cyanosis, clubbing or edema. No report of multiple pressure injuries was noted during the physical exam. At time of admission R1 was weighing 140.0 lbs.
Record review of the Pre-Admission Medical Report requested by Los Angeles Jewish Health (SNF) as a pre-admission requirement to admit R1 to their health center, was signed and dated by R1’s physician on 01/25/2025. No report of multiple pressure injuries was noted. Furthermore, the Comments section indicates the following: “Patient needs help with basic ADLs such as bathing, dressing, grooming, toileting, eating, transferring, meal preparation, housekeeping”.
Record review of the medical records from Mission Community Hospital dated from 02/03/2025 to 02/14/2025: Admission and Discharge papers indicated that R1 was admitted to the ER presenting hypotensive and altered mental status from baseline following diarrhea. The Admitting Diagnoses dated 02/03/2025: were Sepsis, UTI and dementia. Continues on LIC 9099C...4

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250430153711

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERIHOME, INC	FACILITY NUMBER: 195850227
	VISIT DATE: 05/28/2026

NARRATIVE

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4. A Focused Exam was conducted and listed the following: Cardiopulmonary exam: Rate and rhythm normal, heart sounds normal; Peripheral Pulses: normal; Skin Exam: Skin warm, normal in color, dry. Furthermore, a Pertinent Physical Exam was also conducted at the time of admission to the hospital in the areas: Head, eyes, neck, chest, abdomen, upper and lower extremities. No indication of pressure wounds were observed during the exam. However, Discharge Summary dated 02/14/2025, indicated that R1 was treated with antibiotics for infections noted at arrival. Furthermore, the discharge report indicates that R1 was discharged with the following: Povidone-iodine (Betadine) Solution 10%-Cover area daily-Notes: L-trochanter, R-lower back, L-posterior arm, bilateral heel, L-medial and lateral Malleolus pressure injury. Therahoney Gel 42.5 gram (thin layer twice a day)-Notes: Sacrococcyx and lower midback pressure injury: cleanse with NS, pat dry, apply Therahoney gel cover with dressing twice a day. R1 was awaiting placement to be discharged to a Skilled Nursing Facility (SNF) and on 02/14/2025 R1 was admitted to Alameda Care Center.
Based on record review and interviews, the resident was admitted to the facility with existing pressure wounds; furthermore, record review indicates that the home health nurse oversaw the wound care of the resident and provided training and guidance to the facility staff on how to reposition the resident, and the use of adaptive implements. Interviews indicated that facility staff followed the care plan. Therefore, the allegation that staff did not prevent pressure wounds from developing while in care, is deemed Unsubstantiated at this time. Although, a deficiency pertaining to pressure injuries will be cited under separate cover.
Resident sustained an unexplained injury while in care.
On the allegation that the resident sustained an unexplained injury while in care, it was the concern of the Reporting Party (RP), that they observed purple discoloration, which appeared to be a bruise on R1’s back; however, the RP stated that they were not sure how the resident was bruised on their back. To investigate the allegation, the LPA attempted to interview the RP to obtain additional information as to the exact location and size of the bruise; however, the LPA was unable to communicate with the RP. LPA Urena interviewed R1’s representative, staff, Administrator, and home health nurse about the alleged injury/bruise on R1’s back. Interviews revealed that they had not observed nor were they aware of a bruise on R1’s back. Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time.
The Administrator allowed the facility designated staff to sign the report on their behalf.
Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC9099 (FAS) - (06/04)

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