197609826-2-24-2023-31-AS-NGID-D2TT6A-20240226132645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 02/24/2023
Date Signed: 02/24/2023 07:07:07 PM

Substantiated

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
02/17/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230217163933

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: 57	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Nirjara Acharya, Executive Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility does not have window screens.

INVESTIGATION FINDINGS:

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At 10:30am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with the Executive Director and explained the reason for the visit.

As part of this investigation, LPA conducted a physical plant tour 11:00am and interviewed with the Ambassador, Executive Director, Wellness Director, two (2) staff members two (2) MedTechs, three (3) family members, Home Health nurse, facility doctor and five (5) out of seven (7) residents who were able to communicate (between 11:10am to 3:30pm). LPA also obtained copies of pertinent documents relevant to the investigation.

Allegation: Facility does not have window screens.
During the visit LPA conducted a tour of the facility at 11:00am and observed the Dining Rooms and the
Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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-20230217163933

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: 02/24/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Activity room sliding doors were missing the screens. Based on the observations made during the visit LPA has determined that allegation is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D) Exit interview conducted. Appeal rights explained and copy of this report signed and issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230217163933

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 03/03/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well being of residents, emoploees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Admisnitrator is to hire an outside company to replace screens on all sliding doors and windows. Proof of invoice or pictures will be emailed to LPA by POC date.
	8 9 10 11 12 13 14	Based on LPAs observation during the visit conducted today, the dining rooms and activity room sliding doors had no screens. This poses a potential health, safety or personal rights risk to persons 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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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