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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 09/20/2023
Date Signed: 09/20/2023 04:26:27 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.RO, 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
12/02/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20221202154445
FACILITY NAME:GARDEN OF PALMSFACILITY NUMBER:
197609826
ADMINISTRATOR:MENACHEM GINSBURGFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:0CENSUS: 98DATE:
09/20/2023
UNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Rena Hirsch, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident was hit by another resident while in care.

Resident was spit on by another resident while in care.

Facility staff did not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subseqent visit to deliver the findings for the above noted allgegation.. LPA met with Executive Director Rena Hirsch and explained the reason for the visit.

It was reported that a resident was hit by another resident in care. To investigate this allegation, on 12/06/2022 between 3:00pm and 3:30pm, staff interviews were initiated. Interviews revealed that Resident #1 (R1) was struck on the shoulder by Resident #2 (R2). R1 was assessed and it was determined that they were not injured.

Based on interviews there is sufficient information to support this allegation. Therefore, this allegation is SUBSTANTIATED at this time.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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 4
Control Number 31-AS-20221202154445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN OF PALMS
FACILITY NUMBER: 197609826
VISIT DATE: 09/20/2023
NARRATIVE
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It was alleged that a resident was sit on by another resident in care. To investigate this allegation, on 12/06/2022 between 3:00pm and 3:30pm, staff interviews were initiated. Interviews confirmed that R1 was spit on by R2.

Based on interviews there is sufficient information to support this allegation. Thus, this allegation is deemed SUBSTANTIATED at this time.

It was reported that facility staff did not follow reporting requirements. To investigate this allegation, on 12/06/2022 between 3:00pm and 3:30pm, staff interviews were initiated. Interviews confirmed that the incident between R1 and R1 was not reported. On 9/20/2023, between 2:20pm and 2:45pm, the facilities serious incident reports (SIRs) were reviewed. LPA did not see an SIR submitted for the incident between R1 and R2.

Based on interviews and records review, there is sufficient information to support this allegation. Therefore, the allegation is SUBSTANTIATED at this time. Under Title 22, division 6, chapter 8 the following citations was issued and recorded on the LIC 9099D.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20221202154445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS
FACILITY NUMBER: 197609826
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1-Personnal Rights of Residents in all Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met as evidenced by:
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The administrator will submit to licensing in writing what steps the facility will take to keep residents interactions cordial and respectful..
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Based on interviews, staff did not prevent R2 from assualting R1. R1 was not accorded a dignified relationship with R2.

This poses a potential health and safety risk to residents in care.
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Type B
10/04/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1-Personnal Rights of Residents in all Facilities (a)(2) To be accorded safe, healthful, and comfortable accomodations...


This requirement was not met as evidenced by:
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The administrator will submit to licensing in writing what steps the facility will take to keep residents safe from other residents behaviors.
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Based on interviews, staff did not keep R1 safe and in a healthful environment. Staff did not take preventative measures to keep R2 from spitting upon R1.

This poses a potential health and safety risk to residents in care.
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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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20221202154445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS
FACILITY NUMBER: 197609826
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2023
Section Cited
CCR
87211(a)(d)
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87211-Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(d) any incident which threatens the welfare, safety, health of any resdient...
This requirement was not met as evidenced by:
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The administrator will submit in writing to the Department how they will ensure that all incidents pertaining to residents in care are reported to all required entities in a timely manner.
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Based on interviews, the facility staff did not submit an SIR to the licensing deparment or complete an SOC 341 form and send it to other entities.
This poses a potential health and safety risk to residents in care.
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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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4