197609826-5-11-2023-31-AS-NMAN-CWKUHF-20231013153550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:21:02 PM

Unsubstantiated

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
05/02/2023 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20230502162301

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: 79	DATE:	05/11/2023
		UNANNOUNCED	TIME BEGAN:	11:42 AM
MET WITH:	Nairjara Acharyaj		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are not providing authorized representative with current medication list.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial 10day complaint visit on 05/11/2023 at 11:42am. LPA met with the Wellness Director Jessica Perez and explained the purpose of the visit.

LPA conducted a physical plant tour at 11:57am.

It is alleged that staff failed to provide a residents medication list to an authorized representative. To investigate the above allegation, LPA requested and obtained copies of facility files and documents including but not limited to the staff and resident rosters at 12:36pm. LPA interviewed staff at approximately 12:40pm, staff #1 (S1) confirmed they sent R1 Power of attorney (POA) the medication list on 05/04/2023 after speaking to them and receiving the request. During the investigation, LPA reviewed facility records, per an email correspondent, the medication list was attached" and sent to R1 POA on 05/04/2023.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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-20230502162301

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: GARDEN OF PALMS	FACILITY NUMBER: 197609826
	VISIT DATE: 05/11/2023

NARRATIVE

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At the time of the investigation witness #1 (W1) affirmed that they did receive the medication list from S1 right away after speaking to them. Based on interviews, observations and record review, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.
No health and safety hazards are noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

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