197609826-6-16-2023-31-AS-NMAN-CUXT4H-20230822142358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 06/16/2023
Date Signed: 06/16/2023 03:57:13 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
04/10/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230410153937

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:			TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Due to staff neglect, resident was left on the floor for extended period of time

INVESTIGATION FINDINGS:

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It was alleged that on 04/09/2023, the resident #1 (R1) tried to reach for a glass of water and fell out of bed. R1 was on the floor for the extended period of time before staff found him.

To investigate the allegation, on 04/12/2023 at 11:25 A.M., LPA Alvizar requested copies of pertinent documents relevant to the investigation. The documents included but not limited to Physician Report, Need and Service Plan, Internal incident log for the month of April 2023 and copies of the incident reports submitted to Community Care Licensing Office. Between 11:25am – 2:45pm LPA interviewed residents and staff.
At the time of this visit 11:30am, LPM Margaryan and LPA Alvizar reviewed all facility records in the presence of Executive Director, Regional Manager and Wellness Director. At 1:20pm LPA and LPM had a phone conversation with the staff #1 (S1) assisting R1 on 04/09/2023.

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-20230410153937

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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Staff revealed that R1 is being monitored frequently. However, they were unable to specify why and how often they monitor R1.
S1 indicated that R1 was a fall risk resident and was falling 2-3 times a month. S1 had no knowledge if there was a fall prevention plan for R1. S1 is a Med -Tech. However, he was trying to monitor the resident every time he was passing by R1’s room. On 04/09/2023, while passing by R1’s room, S1 heard R1 calling for help and went to assist. R1 was on the floor and had bruises all over their body. S1 was not sure how long R1 was on the floor. He called 911 and R1 was send to the hospital.
A review of R1’s internal incident log for the month of April 2023, revealed that within one month R1 had four un-witnessed fall incidents; on 04/09/2023; 04/25/2023, 04/26/2023 and 04/30/2023.
A review of R1’s need and service plan does not reveal any information regarding R1 being a fall risk resident and/or identifying fall prevention assistance.
No documents were available at the facility to clarify how the facility staff is meeting R1’s un-met needs.
Based on inspection, 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 immediate Health and safety hazard is noted during this visit.
Exit interview was conducted, appeal rights discussed 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: 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)

Page: 2 of 3

Control Number 31-AS-20230410153937

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 87466	1 2 3 4 5 6 7	87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical... condition and that appropriate assistance is provided ... such changes are documented…. and brought to the attention of the resident's physician…	1 2 3 4 5 6 7	ED will provide a written plan of action explaining how they are going to ensure that residents records are updated to identify fall preventation and/or other un-met needs. POC must be completed by 06/19/23
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; The Licensee did not ensure to document changes in R1’s physical condition. 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)

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