197609826-6-16-2023-31-AS-NMAN-CUANKT-20230801103225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 06/16/2023
Date Signed: 06/16/2023 04:10:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
04/06/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230406084104

FACILITY NAME:	GARDEN OF PALMS		FACILITY NUMBER:	197609826
ADMINISTRATOR:	GINSBURG, MENACHEM		FACILITY TYPE:	740
ADDRESS:	1025 N FAIRFAX AVE		TELEPHONE:	(323) 656-7900
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	130	CENSUS: 81	DATE:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Rena Hirsch		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are mismanaging resident's medications

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analyst (LPA) Antonia Alvizar conducted a subsequent visit to the facility to complete investigation initiated on 04/12/2023. LPM and LPA met with the Executive Director (ED) and explained the purpose of this visit. At 9:50AM a Regional Manager (RM) arrived and assisted during this visit.

Staff are mismanaging resident’s medication
It is alleged staff are mismanaging resident #1 (R1)’s medication and R1 does not receive their medication.
During initial visit between 10:15AM to 10:50AM LPA met with staff and toured the physical plant. At 11:25AM LPA requested copies of pertinent documents relevant to the investigation. The documents included, but not limited to R1’s medication administration records, Inventory sheet for personal belongings and facility food menu. At the time of initial visit LPA interviewed residents and staff between 11:25 A.M. – 2:45pm LPA

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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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Control Number 31-AS-20230406084104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS	FACILITY NUMBER: 197609826
	VISIT DATE: 06/16/2023

NARRATIVE

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At the time of this visit at 10:21AM, LPA Alvizar spoke with R1, who told LPA that they did not receive morning medications. Per LPAs and LPMs observation R1 sitting in the dining area since 9:00am having late breakfast and no one approached R1 to assist with medication.
At 11:30am, LPM Margaryan and LPA Alvizar spoke with ED; RM, Wellness Director and med tech. Staff indicated that R1 sometimes refuse to take medications and other times forgets to take medication. Med tech verifies that she did not provide medication assistance at 8:00am. Wellness Director indicated that she dispensed R1’s morning medication on or around 10:30am,
A review of facility record revealed that R1 supposed to receive morning medication at 8:00am. Based on observation, interviews and record review, there is a sufficient information to verify the allegation. Therefore, the allegation is Substantiated at this time.

Under Title 22, Division 6, Chapter 8, following citation was issued and recorded on LIC9099D, No other health and safety hazard is noted during this visit.
Exit interview is conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230406084104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS	FACILITY NUMBER: 197609826
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/16/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	(c)… Facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided … the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	ED will provide a written plan of action explaining how they are going to ensure that residents medications were dispensed as per doctor’s instruction. POC must be completed by 06/19/23
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; Licensee did not ensure that resident’s medication was given as per doctor’s directions. R1’s 8:00am medication was dispensed on or around 10:00am. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
04/06/2023 and conducted by Evaluator Antonia Alvizar

COMPLAINT CONTROL NUMBER: 31-AS-20230406084104

FACILITY NAME:	GARDEN OF PALMS		FACILITY NUMBER:	197609826
ADMINISTRATOR:	GINSBURG, MENACHEM		FACILITY TYPE:	740
ADDRESS:	1025 N FAIRFAX AVE		TELEPHONE:	(323) 656-7900
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	130	CENSUS: 81	DATE:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Rena Hirsch		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not provide adequate food service to residents
Staff does not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analyst (LPA) Antonia Alvizar conducted a subsequent visit to the facility to complete investigation initiated on 04/12/2023. LPM and LPA met with the Executive Director (ED) and explained the purpose of this visit. At 9:50AM a Regional Manager (RM) arrived and assisted during this visit.
Staff does not provide adequate food service to residents
It is alleged that the meals is will not be served until 2-3 hours afterwards. Staff is not feeding R1. Staff interviews revealed that residents are being provided adequate food services. At the time of this visit, at 8:00AM LPM and LPA Alvizar observed breakfast being served and consist of the following: eggs, oatmeal cereal and fruit.
At 9:00am, LPA and LPM observed R1 eating breakfast, At 10:21AM LPA spoke with R1 and they stated that they had breakfast, and it was good. At 12:10PM LPm and LPA observed lunch being served and consist of the following: potato pancake/Latkes, apple sauce, salad, water, apple juice, and Coca-Cola soda. R1 was present during lunch time.
The facility menu was reviewed and it meets Food Service Requirements.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20230406084104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS	FACILITY NUMBER: 197609826
	VISIT DATE: 06/16/2023

NARRATIVE

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Based on observation, interviews and record review, there is an insufficient information to support the allegations. Therefore, the allegation is deemed unsubstantiated at this time.

Staff does not safeguard resident’s personal belongings

It is alleged that R1’s personal belongings are missing and $52.00 was stolen from R1. .
Staff interviews revealed that R1 does not allow facility staff to go to their room and R1 never formally reported to staff the missing money and personal belongings.
A records revealed that R1 refused to inventory their belongigs.
The information revealed from facility records verified the information received from the staff.

Based on observation, interviews and record review, there is an insufficient information to support the allegations. Therefore, the allegation is deemed unsubstantiated at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

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