complaint·January 30, 2026

Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024), Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and administrator Narine Mertkhanyan (A1) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit. Investigation revealed the following: Allegation: Staff did not seek timely medical care for a resident It is being alleged that facility staff failed to provide timely medical care after R1 experienced a fall, which resulted in hospitalization for a leg fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1). During the interview conducted on 11/17/2024, Administrator Narine Mertkhanyan (A1) stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. A1 also reported that R1 was in hospice prior to being admitted and continued hospice with a nurse periodically checking on her throughout the night. On 12/23/2025, LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the allegation. On 12/23/2025, LPA Troy Watson interviewed Residents #2–13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the allegation. LPA Troy Watson obtained and reviewed facility and medical records for R1. Per R1’s Face Sheet, R1 was admitted to the facility on 10/29/2024. A Facility Internal Occurrence Report dated 10/31/2024 states that a caregiver reported R1 had an unwitnessed fall, after which the Wellness Coordinator assessed R1 and noted scratches to the hand but no other injuries. Facility Notes and Alert Charting dated 11/01/2024 indicate that the caregiver reported that on 10/31/2024, R1 was found on the floor. The 11/01/2024 charting also notes that a body check was completed, revealing no injuries other than to the left hand, although R1 complained of leg pain. Facility Notes and Alert Charting dated 11/02/2024 documents that the hospice agency requested an X-ray. CONTINUED ON LIC9099-C LPA Troy Watson reviewed Vitas Hospice notes dated 11/01/2024 through 11/03/2024 which confirm that R1 remained at the facility during that period. On 11/04/2024, Facility Notes and Alert Charting indicate that R1’s family had R1 sent to UCLA. Records from Ronald Reagan UCLA Medical Center show that R1 was admitted on 11/04/2024, and X-rays taken upon admission showing an acute distal fibular diaphysis transverse fracture with half shaft width lateral displacement of the distal fracture fragment. No documents were provided by facility indicating any other medical interventions were provided by facility to R1 from the date of fall on 10/31/2024 to date of hospitalization on 11/4/2024.Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Allegation: Due to lack of supervision, a resident fell resulting in a fracture. It is being alleged that facility staff did not complete a proper assessment of resident (R1) and had no knowledge of R1 being a fall risk, which led to R1 falling and sustaining a fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (administrator 1-A1) regarding the circumstances surrounding R1’s fall. A1 stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. LPA Troy Watson reviewed facility records. Facility provided department with a copy of the Assisted Living Waiver Individual Service Plan dated 04/23/2024, when R1 still lived in their own home, and it identified R1 as a fall risk. LPA Watson requested from the facility a Needs and Service Plan, Fall Risk Plan and Preplacement Appraisal but none were provided. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed records for R1. Facility Internal Occurrence report dated 10/31 states caregiver reported that R1 had an unwitnessed fall. R1 was checked by Wellness Coordinator who noted scratches to R1’s hand but no other injuries. Per medical records from Ronald Reagan UCLA Medical Center, R1 was admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 with a diagnosis of an acute distal fibular diaphysis transverse fracture with half-shaft-width lateral displacement of the distal fracture fragment. CONTINUED ON LIC9099-C R1 was discharged to a skilled nursing facility on 11/08/2024. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A $500 civil penalty was assessed previously on 01/15/2026. An exit interview with Nathaniel Venzon was completed and a copy of this report was provided. California General Durable Power of Attorney for R1, Facility Census (11/05/2024), Physician’s Report for R1 (04/24/24). Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024), Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit. Investigation revealed the following: Allegation: Staff did not notify authorized representative of incident. This complaint alleges that staff failed to contact R1’s authorized representative after R1 was found on the floor. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1) regarding the facility’s response to R1’s fall. A1 stated that the fall in question was the only documented fall R1 experienced during her stay. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed documentation and medical records for R1. Per facility notes / Alert Charting dated 11/04/2024, R1’s family was present at the facility on 11/04/2024. No other notes were provided. Based on information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Resident Service Coordinator Angel Roman and copies were provided.