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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608200
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:55:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/21/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200721135243
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:
11/18/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staci MarmershteynTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff hit resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegation.

As part of this investigation LPA conducted a virtual visit on 7/28/2020 and interviewed the facilty administrator, Resident 1's (R1's) roommate and caseworker; conducted a visit on 11/18/2021 and interviewed the administrator, two staff members, and 7 residents at 12:45pm.

Allegation #1, that "Facility staff hit resident in care," has been unsubstantiated based on the interviews conducted. LPA did not receive any supporting evidence from the complainant to support the allegation, and none of the 3/3 staff, 1/1 witness, or 8/8 residents interviewed between 7/28/2020 and 11/18/2021 corroborated the allegation.
Report reviewed, signed and delivered. Exit interview conducted, no deficienices cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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