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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608200
Report Date: 05/28/2024
Date Signed: 05/28/2024 05:00:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2023 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20230725132639
FACILITY NAME:ALTA VISTA GARDENSFACILITY NUMBER:
197608200
ADMINISTRATOR:STACI MARMERSHTEYNFACILITY TYPE:
740
ADDRESS:829 NORTH ALTA VISTA BLVD.TELEPHONE:
(323) 937-1940
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:70CENSUS: 70DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Staci Marmer, AdministratorTIME COMPLETED:
04:56 PM
ALLEGATION(S):
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Staff did not provide proper care to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint visit to the facility to render the findings of the above noted allegation. LPA met with blank and explained the reason for the visit.

It was alleged that Resident #1 (R1)'s overall health condition was changed, and facility staff did not provide required assistance to meet R1's needs. The complaint investigation was initiated by LPA Evelyn Rios on 07/26/23 and completed by the investigatior Philippe Miles from the Community Care Licensing Investigation Branch. During the investigation on 09/09/2023, Investigator Miles reviewed R1's facility file and hospital records previously requested and received on 08/29/2023. On 10/05/23, Investigator Miles conducted interviews with three (03) facility staff who were assisting R1 and a witness who was involved in R1's care. Staff revealed that due to changes in R1's health condition, R1 was transferred from assisted living to the memory care unit. Staff assisting R1 in the memory care unit noted significant changes in R1's conditon.
Continue on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2023 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20230725132639

FACILITY NAME:ALTA VISTA GARDENSFACILITY NUMBER:
197608200
ADMINISTRATOR:STACI MARMERSHTEYNFACILITY TYPE:
740
ADDRESS:829 NORTH ALTA VISTA BLVD.TELEPHONE:
(323) 937-1940
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:70CENSUS: 70DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Staci Marmer, AdministratorTIME COMPLETED:
04:56 PM
ALLEGATION(S):
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Resident became severely dehydrated while in care resulting in hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint visit to the facility to render the findings of the above noted allegation.

It was alleged that on 07/08/23 that Resident #1 (R1) was sent to the hospital where R1 was observed to be dehydrated. The complaint investigation was initiated by LPA Evelyn Rios on 07/26/23 and completed by the investigator Philippe Miles from the Community Care Licensing Investigation Branch. During the investigation on 09/09/23, Investigator Miles reviewed R1's facility file and hospital records previously requested and received on 08/29/23. On 10/05/23, Investigator Miles conducted interviews with three (03) facility staff who were assisting R1 and a witness who was involved in R1's care. A review of facility records did not reveal any information to verify the allegation. A review of hospital records revealed R1 was observed by a doctor 2 hours after admission to the Emergency Department (ED), when R1 was being transferred from ED to the hospital. At the time of this visit, LPA Valenzuela spoke with facililty staff and they denied that R1 was ever dehydrated at the facility and that they were hospitalized due to dehydration.
Continue on 9099A-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230725132639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
VISIT DATE: 05/28/2024
NARRATIVE
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Based on interviews and record review there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety issues noted at the time of this visit.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20230725132639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
VISIT DATE: 05/28/2024
NARRATIVE
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 R1 looked pale, was not eating well and had decrease in physical functions. However, staff was unable to explain when they started to notice changes in R1's condition and what additional services they were providing to R1 to meet resident's unmet needs.

On 08/07/23, R1 was sent to the hospital after R1's family member visited the facility and requested to call 911. Prior to this visit on 05/17/24 at 11:00am, R1's facility files were reviewed. A physician report dated 07/23/23 did not disclose any information about changes in R1's condition observed by the facility staff. A completed needs and services plan for R1 was dated on 12/19/19 and not updated care and service plan was available for review. Hospital records revealed that at the time of admission to ED, R1 presented with an altered mental status, hypertension, and possible sepsis.

Based on interviews and record review, there is sufficient information to support the allegation. Hence, the allegation is SUBSTANTIATED at this time.

No health and safety issues noted at the time of this visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230725132639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2024
Section Cited
CCR
87464(d)
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87464 Basic Services-(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified and providing...other basic servies...either directly or through outside resources.
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 The Licensee shall submit to Licesning in writing how they will ensure that the needs of all residents in care are met by close of business day on 5/29/24.
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This requirement was not met as evidenced by: Resident #1 (R1) had a change in condition and it was not documented and additional services were provided. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5