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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608200
Report Date: 07/25/2024
Date Signed: 07/25/2024 12:21:45 PM

Document Has Been Signed on 07/25/2024 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALTA VISTA GARDENSFACILITY NUMBER:
197608200
ADMINISTRATOR/
DIRECTOR:		STACI MARMERSHTEYNFACILITY TYPE:
740
ADDRESS:829 NORTH ALTA VISTA BLVD.TELEPHONE:
(323) 937-1940
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 70CENSUS: 70DATE:
07/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staci Marmeshteyn - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this as a result of the Licensee's failure to inform the Department about the Bankruptcy filed on 03/07/24. LPA met with Administrator Staci Mermerhteyn and inform of the reason for the visit.

LPA's record review today revealed that the facility filed a Chapter 11 Bankruptcy on 03/07/24 and informed Long Term Care Ombudsman (LTCO) on 03/25/24 but no record of informing Community Care Licensing (CCL).

Per California Health and Safety Code section 1569.686, you are hereby notified that a $100 civil penalty is being assessed per day. The total civil penalty for a continuous violation shall not exceed $2000. You will receive an invoice in the mail. Payment is due when billed. Payments must be made by a personal business or cashier's check or money order made payable to the "California Department Of Social Services". Please write the facility number and invoice number on your check and include copy of your invoice with the payment. You will find the invoice number on your invoice. DO NOT SEND CASH.



The licensee was notified that a civil penalty is being assessed for failure to comply with this
section and/or failure to report specified events, in writing, within 2 business days to the Department, the state long term ombudsman, all residents, and their representatives. Deficiency cited under Health and Safety code 1569.686.

Pursuant to Health and Safety Code, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted/ Citations issued/ Civil Penalty assessed/ Appeal Rights discussed/ A copy of report


was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2024 12:21 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 07/25/2024 at 11:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
HSC
1569.686(a)(3)

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A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents... in writing, within two business days, of any of the following events, or knowledge of the event: (3) The licensee files for bankruptcy.
This requirement is not met as evidenced by:
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The Licensee agreed to review the Health & Safety Code pertaining to this specific section and will submit a statement of understanding
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Based on record review, the licensee failed to notify the department when they filed for bankruptcy, this poses an immediate health and safety and personal rights risk to the residents in care.
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Type A
07/26/2024
Section Cited
HSC1569.686(c)

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A licensee who fails to comply with this section may be liable for civil penalties in an amount not to exceed one hundred dollars ($100) for each day of the failure to provide notification required in this section. The total civil penalty shall not exceed two thousand dollars ($2,000). If a resident is relocated without the notification required by this section, and suffers transfer trauma or other harm to his or her health or safety, the department may also suspend or revoke the licensee's license and issue a permanent
revocation of the licensee's ability to operate or act as an administrator of a facility anywhere in the state. Suspension or revocation proceedings pursuant to this subdivision shall be conducted in compliance with Section 1569.51.
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A civil penalty of $2000 is assessed today.

The Licensee agreed to review the Health & Safety Code pertaining to this specific section and will submit a statement of understanding.
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Based on record review, the licensee failed to notify the residents and the department of bankruptcy filing, which poses an immediate 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.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
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