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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608200
Report Date: 05/27/2022
Date Signed: 05/27/2022 02:55:40 PM

Unfounded


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
10/15/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20211015115643
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:
05/27/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staci MarmershteynTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained severe pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. Initial visit was conducted by LPA Lacy on 10/18/2021. This complaint was investigated by Investigation Branch (IB) Investigator Edward Hector.
It is alleged that resident # 1 (R1) was admitted to Kaiser Los Angeles Medical Center on 10/08/21 with a stage four pressure injury on their tailbone from Brier Oaks Skilled Nursing facility. R1 allegedly arrived at Brier Oak Skilled Nursing facility two weeks before being admitted to the hospital already having pressure injuries. On 10/20/2021 interviews were conducted with facility staff and it was confirmed that R1 left the facility on 8/30/21 to go to Cedar Sinai hospital due to having a hard time breathing and never returned to the facility. On 10/20/21 interviews and medical documentation was obtained and reviewed from Brier Oaks Skilled Nursing facility. Interviews and a review of medical documentation revealed that R1 was admitted to Brier Oaks from the hospital on 9/12/21. When R1 came on 9/12/21, an assessment was done and R1 was diagnosed with stage three pressure injury on their sacral area.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
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 2
Control Number 31-AS-20211015115643
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: 05/27/2022
NARRATIVE
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Information obtained through interviews and medical documentation it is found that the last time R1 was at the facility was 8/30/21. R1 was admitted to Kaiser Hospital on 10/8/21 with a stage four pressure injury after being at Brier Oaks Skilled Nursing facility since 9/12/21. Based on all the information obtained this allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit Interview conducted.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2