complaint·January 29, 2026

Pg. 2 On 06/13/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegation listed above. The LPA was greeted by staff and contacted the Administrator. The Administrator Anahit Balasanyan arrived shortly thereafter, and the LPA informed them of the reason for the visit. The Administrator stated that they had recently become the administrator for the facility. The LPA requested documents pertinent to the investigation. The Administrator was advised that the complaint was referred to the Investigations Branch (IB). R1 resided at this location, prior to licensure when operating unlicensed from approximately 08/30/2024 through 01/17/2025. On 01/17/2025, R1 was hospitalized and discharged to a skilled nursing facility on 01/23/2025 until 03/28/2025. On 03/28/2025, R1 was discharged to another unlicensed location until 04/12/2025. R1 returned to this location on 04/12/2025 and remained until hospitalized on 05/13/2025. The facility’s license was granted on 04/28/2025. On 05/14/2025, the Department received complaint control # 29-AS-20250514101524 which is currently pending investigation. On 06/23/2025, Investigator Luckett issued a subpoena to the Los Angeles County Department of Medical Examiner requesting R1’s autopsy records. On 07/07/2025, Investigator Luckett requested any police reports pertaining to R1 from the Los Angeles Police Department (LAPD). On 07/23/2025, a request for Emergency Medical Services (EMS) records was submitted, and a subpoena for records at Valley Presbyterian Hospital was issued. On 07/23/2025, Investigator Santana conducted a telephone interview with a LAPD Detective. On 07/24/2025, a review of EMS records was conducted. Continues on LIC 9099C page 3. Page 3. On 08/01/2025, Investigator Santana conducted a telephonic interview was conducted with the assigned investigator at the County of Los Angles Department of Medical Examiner (Witness #1(W1)). W1 stated the case was referred to the Medical Examiner due to report of suspected elder abuse. R1 was transported to the Medical Examiner’s office on 06/06/2025. Hospital records from Valley Presbyterian indicated R1 was initially doing okay and was set to be discharged to a skilled nursing facility but a nurse noticed R1 had an acute worsening of their mental status on 05/19/2025. It was discovered through a CT scan that R1 suffered a stroke and brain bleed. R1 was placed on comfort care. W1 did not interview anyone at the facility as a part of their investigation due to R1’s condition improving and the hospital and R1 getting ready to be discharged. On 06/09/2025, R1 had a complete autopsy with the manner of death being determined as natural with underlying hypertension and type 2 diabetes. The autopsy did not show physical evidence of neglect. On 08/04/2025, subpoenas for records were issued to Mission Community Hospital during the time period of 09/01/2024 through 05/14/2025, Owl Western Pharmacy, and skilled nursing facility Brier Oak on Sunset. On 08/05/2025, at approximately 8:05 a.m., a Licensed Vocational Nurse (LVN), (Witness #2) was interviewed. W2 assists sister hospice agency Franklin Hospice. On 05/13/2025, an unknown man from Franklin Hospice contacted W2 and requested W2 visit R1 due to a possible issue with a Foley catheter and R1’s nurse from Franklin Hospice being unavailable. When W2 arrived, the caregiver stated R1 had not taken any medication and was also not taking any fluids. The Foley catheter was in place but there was red tinged urine in the bag. When W2 asked the caregiver where R1’s medication was, the caregiver gave W2 a bin of medication. Continues on LIC 9099C page 4. Page 4. The bin included expired insulin, opened insulin pens, and oral diabetes medication, but the caregiver said they had never given R1 any of the medication. W2 explained to the Investigator that an opened insulin should not be used after 28 days. W2 said R1’s blood pressure was pretty high, and when W2 asked for a blood glucose meter by gesturing, the caregiver handed one to W2. R1’s blood sugar was over 500 mg/dL. W2 called Franklin Hospice to advise they would be calling 911 because R1’s was having a medical emergency unrelated to the reason R1 was on hospice and that R1’s current condition did not appear to be from natural causes. Franklin Hospice had ordered insulin earlier that day, and the Medical Director instructed W2 to administer 10 units of it. When W2 checked R1’s blood sugar level again, it had only gone down to around 400 mg/dL, and the Medical Director may have instructed them to give additional insulin units, but W2 decided to call 911. A total of four clients were taken to the hospital. On 08/06/2024, a subpoena for records was submitted to Franklin Hospice for the time period of 09/01/2024 through 05/14/2025. On 08/07/2025, at approximately 12:50 p.m., an interview was conducted with (Witness #3) at the County of Los Angeles Department of Medical Examiner’s office. W3 said R1’s case became a Medical Examiner case because a detective reported concerns of neglect. W3 determined R1’s cause of death as intracerebral hemorrhage based on a CT scan and autopsy done at their office. R1’s hypertension and type 2 diabetes were listed as other significant conditions because they increase the risk of having a brain bleed, but hypertension is probably the most common cause of stroke. The examination showed R1’s condition was consistent with having had a stroke, and there was no indication of head trauma. W3 found there to be a lot of hemorrhaging in R1’s left brain. The stroke W3 observed was recent relative to the time of her death, but W3 cannot tell if R1 had prior strokes. Continues on LIC9099C page 5. Page 5 . W3 said R1’s stroke was spontaneous, but it is difficult for W3 to say whether appropriate treatment of R1’s diabetes could have prevented the stroke and ultimate death. W3 concluded the manner of death to be natural. On 08/07/2025, Investigator Santana obtained a copy of the R1’s autopsy records. A summary of the records reflect R1 was pronounced dead on 05/28/2025 at 0603 hours (at Valley Presbyterian Hospital). W3 of L.A. County Department of Medical Examiner examined R1’s body on 06/09/2025 and found the cause of death to be intracerebral hemorrhage with other significant conditions of hypertension and type 2 diabetes. The manner of death was found to be natural. Law enforcement expressed concerns that facility conditions were unsanitary, but autopsy did not show physical evidence of neglect or abuse. Examination was performed after two weeks of hospitalization. Based on hospital records, W3 summarized R1 was initially taken to Mission Community Hospital on 05/13/2025 but was then transferred to Valley Presbyterian Hospital on 05/14/2025. Janet was admitted for altered mentation, sepsis, and UTI. On 5/19/2025, R1 was stabilized and pending discharge but suffered an acute worsening in mental status. A head CT scan showed new focal hypoattenuation in the left MCA territory, and R1 was later found to have suffered a large ischemic stroke and hemorrhagic conversion. Because R1 was not believed to be a surgical candidate, R1 was placed on DNR/DNI comfort care, and R1 was pronounced dead at 0603 hours on 05/28/2025. On 08/08/2025, at approximately 1:05 p.m., R1’s next of kin (Witness #4) was interviewed . W4 did not have a close relationship with R1 and did not know about R1’s placement or R1’s medical condition but believed R1 had strokes and or seizures as a result of a head injury that occurred 2-3 years ago. Continues on LIC 9099C page 6. Page 6. On 08/08/2025, records from Brier Oak on Sunset were received. Review revealed R1 resided at the skilled nursing from 07/24/2024 through 08/30/2024. At the time of discharge, R1’s active orders included prescriptions for Januvia, Humulin R, and Basaglar KwikPen. Instructions were to inject 30 units from the insulin pen two times a day and use additional injections per sliding scale. On 08/11/2025, records from Mission Community Hospital were received. A review revealed R1 was admitted to Mission Community Hospital at 1940 hours on 5/13/2025 with an admitting diagnosis of hyperglycemia. The LAFD EMS Captain advised that the facility knew nothing about R1 and only provided a box full of medications. According to the Captain, R1 would be unable to return to the facility. In the emergency room, R1 had a blood sugar of 475 mg/dL, and was given 10 units of insulin. A head CT scan showed no acute hemorrhage, hydrocephalus, or mass effect. R1 was not able to ambulate but had no apparent distress, pain, or shortness of breath. R1 was found to have dermatitis on the buttock. R1 was discharged at 0423 hours on 05/14/2025 to Valley Presbyterian Hospital with a blood sugar of 258 mg/dL. Discharge diagnosis was sepsis, with other diagnoses including encephalopathy, type 2 diabetes with hyperglycemia, and hypertension. On 08/13/2025, at approximately 0835 hours, an email request to LAPD Communications Division for the call for service log at the facility address from 01/01/2025 – 05/13/2025 was submitted. On 08/13/2025, a review of records from Owl Western Pharmacy revealed Owl Western Pharmacy filled for R1 glipizide, delivered on 3/19/2025; Lantus, delivered on 3/07/2025; and Humulin R, delivered on 3/07/2025. All of these were prescribed by a physician at Maclay Healthcare Center on 3/06/2025.On 08/14/2025, a subpoena for records was submitted to Maclay Healthcare Center. On 08/15/2025, a review of LAPD’s call for service log revealed a call for service on 04/01/2025 unrelated to R1. Continues on LIC9099C page 7. Page 7 . On 08/15/2025, a review of Franklin Hospice records revealed R1 was admitted to Franklin Hospice on a routine level of care on 08/31/2024 after being referred that day by a physician (Witness #5) with a primary diagnosis of hypertensive heart disease. Although the “Narrative Summary of Prognosis Documentation” that was docu-signed by the physician notes R1’s diagnosis as “Hemiplga following cerebral infrc aff left dominant side.” R1’s Plan of Care, which was incorrectly dated 08/13/2025, was drafted by hospice RN. It indicates a health aide would provide R1 with personal care assistance twice a week. For diabetes, R1’s blood sugar would be checked routinely, and caregivers would avoid giving sweets. Caregivers would administer metformin, Januvia, Jardiance, Humulin R KwikPen, and Basaglar KwikPen. RN’s 08/31/2025 Comprehensive Nursing Assessment said R1 was admitted for hemiplegia with other conditions of diabetes, unsteadiness on feet, and generalized muscle weakness. It was noted R1 had a personal history of ischemic heart attack and cerebral infarction without residual. Weekly skilled nursing visits between 09/08/2024 – 01/13/2025 were made by LVN. Caregivers reported R1’s blood sugar was sometimes high and R1 refused insulin at times. The LVN educated caregivers on reportable signs of hypo/ hyperglycemia, with caregivers verbalizing understanding. During some of the LVN’s visits, caregivers reported elevated blood sugar, so the LVN reminded caregivers to consistently monitor and record Janet’s blood sugar levels and to promote healthy eating habits. R1 was discharged from hospice on 01/17/2025 due to hospitalization after complaints of chest pain and trouble breathing. R1 was readmitted to Franklin Hospice on a routine level of care on 03/31/2024 after being referred that same day by same admitting physician, with a primary diagnosis of hypertensive heart disease.During the LVN’s (Witness #6) weekly visits, the LVN made no reference to R1’s diabetes. The LVN’s first visit was on 4/01/2025, but they did not visit again until 04/18/2025. On the 04/24/2025 updated assessment, it noted that caregiver “Anna” was present and actively participated in R1’s care. There was no skin breakdown. No medication refills were needed during that visit. LVN visited again on 04/25/2025 and noted no physical signs of distress, with vitals within normal limits. When LVN visited on 05/13/2025, at around 0900 hours, they noted R1’s blood pressure at 190/98, which was higher than at any prior visit within that certification period. R1 was non-verbal and had a pulse of 101 and respirations at 20. LVN administered Clonidine to address the elevated blood pressure. No safety issues or incidents were reported to the LVN during the visit. Continues on LIC 9099C page 8. Page 8. Later that same day at approximately 1800 hours, hospice nurse W2 visited the facility and noted R1’s blood pressure as 157/101 and temperature at 100.8. W2 documented that they received a call from Franklin Hospice requesting a PRN visit because a caregiver reported R1 was not feeling well. According to office staff, medications were delivered earlier that day. The caregiver brought W2 a box with medications and a bag of medications delivered that day. W2 observed insulin to be opened and likely past 28 days of opening. When W2 assessed R1’s blood sugar it was 476 mg/dl and notified W7. W7 ordered 10 units of insulin. Thirty minutes later R1’s insulin was 469 mg/dL and W2 noticed W7 they would be calling 911 and W7 agreed. On 08/27/2025, an interview was conducted with Staff #1 (S1). S1 stated when they worked at the facility when it was previously unlicensed in June 2024, they checked R1’s blood sugar everyday and gave insulin when instructed by the hospice nurse. On 08/27/2025, an interview was conducted with Staff #2 (S2) who began working at the facility on 05/01/2025. S2 stated they knew R1 was diabetic but R1 was not receiving insulin. On the morning of 05/13/2025, the NOC staff did not mention anything about R1 but S2 noticed R1’s face was red. When the hospice nurse arrived around noon, R1’s blood sugar was high and insulin was ordered. Between 1600-1700 hours, the insulin was received and a different nurse administered it but R1’s blood sugar was still high so 911 was called. On 09/04/2025, an interview was conducted with Witness #7 (W7), Medical Director of Franklin Hospice. W7 was not aware R1 should have been taking diabetes medications both oral and by injection until 05/13/2025 when W2 contacted them regarding R1’s blood sugar. W7 advised W2 to give R1 insulin.On 9/04/2025, at approximately 11:20 a.m., R1’s Hospice Nurse / Licensed Vocational Nurse (LVN) Witness #6 (W6) working for Franklin Hospice was interviewed via Facetime video chat. W6 stated when R1 was discharged from the SNF and returned to hospice, the SNF discontinued R1’s diabetes medications and the RN who readmitted R1 followed the orders. As a result, the facility was no longer required to check R1’s blood sugar. W6 did not recall checking R1’s blood sugar during that time.Continues on LIC 9099C page 9. Page 9 . On 09/05/2025, an interview with Licensee Edgar Zatikian with the assistance of the facility Administrator serving as an Armenian translator was conducted. Zatikian owns the facility and works as the sole overnight caregiver. Zatikian denied the facility administering insulin injections to R1 at any time, either before or after being licensed. Zatikian stated when R1 returned in April 2025 they did not return with insulin, Zatikian denied knowing about insulin being observed in the facility by LAFD or W2 on 05/13/2025. Zatikian stated they knew R1 had diabetes, but no one explained why R1 was not receiving diabetes medications. On 09/05/2025, a review of additional records from Maclay Healthcare Center was conducted. When R1 was discharged from the SNF, discharge documents were sent on 03/28/2025 to A Better Solution home health agency with oral diabetes medications and insulin orders and the resident was transported to an unlicensed location. On 09/05/2025 an interview was conducted with Witness #5 (W5) who was the referring physician from Franklin Hospice. W5 stated they no longer work for Franklin Hospice as of August 2025. W5 acknowledged their e-signature on R1’s 03/31/2025 but was unsure whether they signed it because of concerning practices. W5 did not know R1’s medication list and no longer had access to that information. On 09/08/2025, an interview was conducted with Witness #8 (W8). W8 stated R1 was referred to A Better Solutions but when the home health agency went to visit R1 at the unlicensed location they refused services and explained the facility had their own home health or hospice services. On 09/09/2025, a review of pharmacy records prescribed on 04/03/2025 by W7 reflect no medications for diabetes. On 9/11/2025, at approximately 12:35 p.m., R1’s attending Physician at Valley Presbyterian Hospital, Witness #9 (W9) was interviewed via Teams video chat. When asked, W9 stated a lack of diabetes medications could have contributed to R1’s stroke. However, damage to arteries occurs over a span of years and does not happen overnight. Continues on LIC 9099C page 10. Page 10 . On 09/12/2025 an interview was conducted with Witness #10 (W10) who is an LVN at Franklin Hospice. W10 stated when R1 was assessed on 03/31/2025, R1 initially refused insulin and blood sugar checks but later agreed. W10 also stated Maclay Healthcare Center did not provide a medication list initially but later provided one. Interviews and record review revealed that on 05/13/2025, R1 was hospitalized for hyperglycemia, and a CT scan was performed on R1; there were no acute findings on R1’s head CT scan at that time. After signs of R1’ condition improvement, the hospital was going to discharge R1 to a skilled nursing facility (SNF), however R1 had a change in mentation on 05/19/2025. A CT scan at Valley Presbyterian Hospital showed that R1 likely suffered a stroke, and additional testing showed presence of multiple additional strokes occurring at the hospital. R1 passed away at the hospital on 05/28/2025. R1’s attending physician was unable to say whether R1’s strokes could have been prevented had R1’s diabetes been properly managed. The County of Los Angeles Deputy Medical Examiner (DME) concluded that R1’s death to be natural and resulting from intracerebral hemorrhage with contributing factors of diabetes and hypertension, furthermore the DME did not find any immediate indicators of abuse or neglect. R1 had a complete autopsy on 6/09/2025, with the manner of death being determined as natural with underlying hypertension and type 2 diabetes. According to the DME, the autopsy did not show physical evidence of neglect. R1’s stroke was spontaneous, but it is difficult for the DME to say whether appropriate treatment of R1’s diabetes could have prevented the stroke and ultimate death. DME concluded the manner of death to be natural. The allegation that R1’s death was due to facility’s neglect, is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.