197609826-2-20-2024-31-AS-NGID-D2UQUW-20240227112923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 02/20/2024
Date Signed: 02/20/2024 06:41:55 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
02/23/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230223083817

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:	0	CENSUS: 106	DATE:	02/20/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Adam Suncheff, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff leave resident in soiled diaper for extended periods
Staff failed to adequately feed resident
Staff failed to meet resident's needs
Resident sustained multiple falls while in care
Staff failed to provide a safe and comfortable environment

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 10:30am, Licensing Program Analyst (LPA) Angela Panushkina a subsequent visit to deliver final findings. LPA met with the Executive Director and explained the reason for the visit.

During the initial visit made on 02/24/2023, by LPA Panushkina interviews and record reviews were made. At 10:30am, LPA requested resident and staff roster. At 10:35am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc. relevant to the investigation. At approximately 11:00am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 11:10am – 3:00pm, LPA Ambassador, Executive Director, Wellness Director, two (2) staff members two (2) MedTechs, three (3) family members, and five (5) out of seven (7) residents who were able to communicate.
Continue on LIC9099-C

Unsubstantiated

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: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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 3

Control Number 31-AS-20230223083817

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: 02/20/2024

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

Allegation: Staff leave resident in soiled diaper for extended periods

It was alleged that residents are left soiled for an extended time. To investigate the allegation on 02/24/23, LPA conducted physical plant tour at around 11:00am, and observed that all residents were clean and well-groomed, and LPA did not experience any malodor. During interviews with staff, all staff stated they check on all incontinent residents every two hours, change them two (2) or three (3) times per shift or as needed and do not leave residents soiled for an extended time. Interviews with five (5) out of seven (7) residents expressed to concern regarding this allegation. Based on the information gathered during the initial visit, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff failed to adequately feed resident

Regarding the allegation that the staff failed to adequately feed resident, LPA conducted interviews with four (4) staff members. Interviews with four (4) staff revealed that some residents in a Memory Care Unit require assistance with feeding and the facility has enough staff to provide help. Moreover, interviews with five (5) out of seven (7) residents, who were able to communicate, revealed that they have witnessed the facility staff helping residents with their meals. Based on the information gathered during the initial visit, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff failed to meet resident's needs

It was alleged that R1 has Dementia, and the staff are failed to meet R1's needs by leaving him/her unattended in a soiled diaper for extended periods. To investigate the allegation on 02/24/23, LPA conducted physical plant tour at around 11:00am, and observed that all residents were clean and well-groomed, and LPA did not experience any malodor. During interviews with staff, all staff stated they check on all incontinent residents every two hours, change them two (2) or three (3) times per shift or as needed and do not leave residents soiled for an extended time. Moreover, all staff interviewed informed LPA that all residents are scheduled to have showers at least two (2) or three (3) times a week or as needed. Lastly, Interviews with five (5) out of seven (7) residents expressed to concern regarding this allegation. Based on the information gathered during the initial visit, this allegation is deemed Unsubstantiated at this time.

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230223083817

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: 02/20/2024

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

Allegation: Resident sustained multiple falls while in care

It was alleged that R1 sustained multiple falls while in care. LPA was able to speak with four (4) staff and five (5) residents regarding this allegation. LPA was also able to review all Physician Communication documents, which detailed the falls of the resident in question (R1). Although, the R1 did sustain multiple falls, the falls occurred while R1 was in the presence of caregiver or while alone in his/her apartment. Staff always responded to the falls and the facility had increased checks on the resident to hourly during the night. Based on the information gathered during the initial visit, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff failed to provide a safe and comfortable environment

It was alleged that on 02/21/23, R1's family member went to the R1's room and noticed that the room was locked, and R1 was left unattended in the room. To investigate this allegation, LPA conducted an interview with the Ambassador, Wellness Director, two (2) staff members and two (2) MedTechs. LPA was informed that on 02/21/23, R1 was sent to the hospital and when returned to the facility, on the same day, the facility staff communicated through WhatsAppto update each other regarding R1's current status. LPA was also informed that when R1 came back from the hospital he/she was very weak and the staff took R1 to the room to get some rest. In addition, all staff interviewed informed LPA that R1 was being checked on every one (1) hour. Moreover, during the initial visit, LPA also conducted a walk through in the Memory Care Unit and observed that residents' doors had locks. Interview with the Ambassador and two (2) staff members revealed that once the resident enters the room, the door automatically locks to prevent other residents, with wondering behavior, to enter and disturb the resident. Although, the doors had locks, LPA observed staff members periodically checking each room to make sure the residents are safe. Based on the information gathered during the initial visit, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3