197608200-7-26-2025-31-AS-TAGD-DKWMLH-20250826094221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608200
Report Date: 07/26/2025
Date Signed: 07/26/2025 01:21:21 PM

Unsubstantiated

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
01/27/2025 and conducted by Evaluator Angelica Segovia

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250127093808

FACILITY NAME:	ALTA VISTA GARDENS		FACILITY NUMBER:	197608200
ADMINISTRATOR:	STACI MARMERSHTEYN		FACILITY TYPE:	740
ADDRESS:	829 NORTH ALTA VISTA BLVD.		TELEPHONE:	(323) 937-1940
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	70	CENSUS: 70	DATE:	07/26/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Debrah Dapson- Designee		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident in care.
Staff did not prevent resident from harming another resident in care.

INVESTIGATION FINDINGS:

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On 7/26/2025 at approximately 9:40 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by staff and stated the reason for their visit was to conduct interviews, review documentation and deliver the findings of the complaint. The Administrator, Staci Marmershteyn was unavailable to attend today’s visit and designated lead staff, Debra Dapson as the facility’s designee.

At 09:45 AM, LPA requested census, resident and staff roster. At approximately 10:00 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. At 11:00 AM, LPA requested pertinent documentation pertaining to the investigation such as but not limited to: Physicians Report, Admission Agreement and the Centrally Stored/Destruction Medication (CSDMR). In between 11:15 AM – 1:00 PM, LPA attempted interviews with eight (8) residents (R1-R8), two (2) staff members (S1-S2) and conducted record review.
(Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025

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 3

Control Number 31-AS-20250127093808

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: 07/26/2025

NARRATIVE

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Regarding the allegation: Staff did not seek medical attention for resident in care. It was alleged that R1 was not provided with medical attention. To investigate the allegation, LPA interviewed two (2) staff members and attempted to interview seven (7) residents. LPA’s interview with both staff members revealed that when they were made aware of R1 seeking treatment, they attempted to assist them but R1 declined. S2 stated that when they asked R1 if they required, “…medical attention…” R1 stated they did not want any. LPA attempted to interview R1 but R1 was not present during the visit and could not be reached. LPA’s interview with six (6) out of the seven (7) residents confirmed that if they needed medical attention the facility would provide such services.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff did not prevent resident from harming another resident in care. It was alleged that R1 was physically assaulted by R2 and staff did not prevent the altercation from occurring. To investigate the allegation, LPA interviewed two (2) staff members and attempted to interview eight (8) residents. LPA’s interview with both staff members revealed that R2 did not have a history of aggressive behaviors towards other residents, however R1 has had a history of aggressive behavior towards other residents. Interview with S1 revealed that when they became aware of a possible incident occurring between R1 and R2, they self-reported the incident on an Unusual Incident/Injury Report (SIR). LPA’s interview with S2 revealed that they removed R2 from their shared living space to help mediate the situation. Both staff members stated that R2 denied that they had physically assaulted R1.

LPA’s interview with two (2) out of the eight (8) residents confirmed that they have had prior incidents involving R1’s aggressive behavior. Interview with R3 revealed that R1 would become upset with them and had even once restricted their access into shared spaces within the facility. Interview with R4 confirmed that they too had prior incidents regarding R1’s behavior. R4 stated that R1 always wanted to fight them and would, “threaten” them all the time. Interview with R3 and R4 confirmed that the facility did ensure to minimize said incidents by removing them away from R1 to ensure all could coexist safely. LPA’s interview with R5 revealed that their interactions with R2 were always amicable. LPA attempted to interview R2 but R2 no longer resides at the facility and could not be contacted. LPA attempted to interview R1, but they were not present during the visit and could not be contacted. LPA’s interview with R6, R7 and R8 revealed that they have not had any interactions with R1 and R2. LPA’s record review confirmed that the facility did report the incident to Community Care Licensing Division (CCLD). (Continue to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250127093808

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: 07/26/2025

NARRATIVE

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Further record review revealed that R1 has various medical diagnosis with some resulting in possible side effects including agitation.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the lead staff designee.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025

LIC9099 (FAS) - (06/04)

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