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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191800001
Report Date: 08/08/2024
Date Signed: 08/08/2024 09:57:28 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240802132026
FACILITY NAME:HOLLENBECK PALMSFACILITY NUMBER:
191800001
ADMINISTRATOR:DIANA MEDINAFACILITY TYPE:
741
ADDRESS:573 S. BOYLE AVETELEPHONE:
(323) 263-6195
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:185CENSUS: 168DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Administrator Diana MedinaTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff financially abused resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/08/2024 regarding the above allegation. LPA Ramirez was greeted by Administrator Diana Medina and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 interview (S1), Resident#1 (R1) Admission Agreement, Resident Assessment Report, Emergency Notification Form, Physician Report, and physical plant tour.
The investigation revealed the following. Regarding Allegation: Staff financially abused resident- It is alleged R1 withdrew large amounts of money from R1’s 401k account and gave it to the facility.

SEE 9099-C for continued narrative.
Unfounded
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20240802132026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLLENBECK PALMS
FACILITY NUMBER: 191800001
VISIT DATE: 08/08/2024
NARRATIVE
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The facility is licensed as a Residential Care Facility for the Elderly/Continuing Care Retirement Community. Upon record review, it was revealed R1 resides in the facility independent living accommodation and has an Admissions agreement to corroborate R1 does not receive care and supervision from the facility. Per Health and Safety Code section 1569.80 (e)- If the residential care facility for the elderly is a continuing care retirement community, as defined in paragraph (10) of subdivision (c) of Section 1771, this section shall apply only to residents who require care and supervision, as defined in subdivision (b) of Section 1569.2."

Based on the records reviewed and interview conducted, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2