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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608200
Report Date: 05/10/2022
Date Signed: 05/10/2022 10:01:20 AM

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
01/14/2021 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20210114093851
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:
05/10/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Deborah DopsonTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident caused injuries to another resident while in care
Staff did not address a resident's change in medical condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to the facility to conclude the investigation regarding the above allegations. The 10-day visit was made by LPA Elizabeth Arambulo. Complaint was then referred to Investigations Branch (IB). It was accepted and assigned to investigator Jose Santana as a full assignment. IB’s investigation consisted of interviews with staff and residents, and a review of Resident 1 (R1) medical records.

Resident caused injuries to another resident while in care:
In regards to the allegation, it was reported that on or around 11/26/19, R1 was assaulted by Resident 2 (R2). The investigation reveals that it was known R2 disliked sharing rooms with R1. Prior to the assault, on or around 11/23/19, staff had observed R2 punching R1 several times because he disliked sharing rooms. Facility had documented the incident with the resolution for room reassignment. The reassignment did not occur. Furthermore, the incident was not reported to the Department of Health Services (DHS). Had this conflict been known, DHS would have taken steps to address the issue, and
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
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-20210114093851
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: 05/10/2022
NARRATIVE
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possibly preventing the incident to occur on 11/26/19. Based on the information obtained, there is enough information to corroborate with the allegation of resident causing injury to another resident while in care. Therefore, the allegation is Substantiated. Citation(s) issued on the 9099D.

Staff did not address a resident’s change in medical condition:
In regards to the allegation, it was reported that on or around 10/30/20, R1 was treated for an edema. R1 received instructions to follow up with their primary doctor in one to two days, or to return to the emergency room if symptoms worsened. The investigation revealed that there was no follow up appointment with R1’s primary doctor. R1 wasn’t seen until 2/3/21. Between 10/30/20 to 11/26/20, there was documentation that R1 experienced swelling and redness on six different days, but no record of a hospital visit or attempts to treat R1’s condition. Additional documentation also noted that on 11/24/20, R1 had a “little open hole” to their ankle, but no notation that it was being treated. Based on the information obtained, there is enough information to corroborate with the allegation of staff not addressing R1’s change in condition. Therefore, the allegation is Substantiated. Citation(s) issued on the 9099D.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210114093851
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: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement has not been met as evidenced by
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As POC, the licensee will review this section of the regulation and self certify that they have read and understood the section. POC due to the licensing agency by 5/17/22.
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Prior to R2 assaulting R1 on 11/26/19, R2 was also involved in another assault with R1 on or around 11/23/19. Licensee failed to notify DHS of R2’s behavior, which could have helped in taking steps to prevent another assault from happening.
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Type A
05/10/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging,
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Furthermore, licensee failed to take R1 to the emergency room as instructed when R1 was experiencing swelling and redness for six days.

As POC, the licensee will review this section of the regulation and self certify that they
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for medical and dental care appropriate to the conditions and needs of residents. This requirement has not been met as evidenced by: The licensee failed to make a follow up appointment with R1’s primary doctor who instructed them to do so after being treated for an edema. Cont.
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have read and understood the section. POC due to the licensing agency by 5/17/22.
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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
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