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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608200
Report Date: 12/30/2021
Date Signed: 12/30/2021 04:13:47 PM

Substantiated


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
12/28/2021 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20211228144047
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:
12/30/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Deborah DopsonTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not provide required medical care to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial complaint visit to investigate the allegation above. LPA meet with staff Deborah Dopson and explained the purpose of this visit.
It is alleged that resident #1 (R1) oxygen levels were low, due to not receiving prescribed Oxygen treatment. To investigate the allegation, LPA conducted a physical plant tour at 10:45am and observed no immediate health and safety concerns. At 11:01am LPA requested and reviewed copies of relevant documents pertinent to the investigation. Based on document review R1 received the prescribed oxygen machine delivered on 12/08/2021 at 6:20pm to the facility. Upon review of discharge documents from the hospital dated 12/24/2021, although, the Oxygen Therapy listed as a Home Treatment, it has not been documented by the facility as a part of R1s Needs and Service Plan. During the investigation, at approximately 11:10am LPA began interviews with facility staff. Interviews revealed that the staff had knowledge about the oxygen concentrator delivered to the facility. However, they did not follow up with the order to clarify who is was prescribed to and how they were supposed to assist the resident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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 4
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
12/28/2021 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20211228144047

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:
12/30/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Deborah DopsonTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are not showering resident.
INVESTIGATION FINDINGS:
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It is alleged that R1 is not being bathed regularly. To investigate this allegation, at approximately 11:10am LPA interviewed staff and they indicated that some residents receive two (2) showers a week, other residents more if necessary. If the resident refused, then they are asked the following days until resident agree to take a shower. At 11:36am LPA spoke with seven (07) out of seventy (70) residents. Interviews revealed that four (4) out of seven (7) residents receive two showers a week. One (1) out of (7) residents is independent and does not need assistance with showers. One (1) out of (7) residents receives hospice assistance. LPA observed two (2) shower rooms, (1) in memory care and the other on the assisted living side. The shower rooms were equipped with adequate supplies of wash and dry towels for single use, floor pads to soak up excess water and hygiene supplies (body wash, deodorant, shampoo and conditioner, etc). Based on observations and interviews there is an insufficient information to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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 4
Control Number 31-AS-20211228144047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
VISIT DATE: 12/30/2021
NARRATIVE
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 At 11:36am, LPA spoke with seven (7) out of seventy (70) residents they all did not address any concerns about their medical care. Overall investigation revealed that, although R1’s oxygen concentrator was delivered to the facility, staff did not ensure to assist R1 Oxygen administration as needed.

Based on the information obtained through observations, document review and interviews, there is a sufficient information to support the allegation. Therefore, allegation is deemed Substantiated at this time.

Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20211228144047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2021
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical …care appropriate

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Licensee will contact R1 Medical Physician to obtain a plan of care to ensure that residents incidental medical needs are provided. Licensee will submit to LPA the written plan of care from the physician.
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to the conditions and needs of residents. This requirement is not met as evidenced by; The licensee did not develop an incidental medical care for C1. C1 was not receiving O2 treatment as prescribed. This poses an immediate health and safety risk to clients 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: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4