197609826-6-23-2023-31-AS-NMAN-D8HMS4-20240826095116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:33:51 PM

Unsubstantiated

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
06/20/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230620084658

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:	06/23/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Rena Hirsch, Executive Director		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility has shortage of incontinent supply

INVESTIGATION FINDINGS:

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At 10:15AM Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with the Executive Director and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:25AM, LPA met with the Administrator and requested resident, staff roster and, staff schedule. At 10:30AM, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Appraisal Needs and Services Plan, Resident Appraisal Unusual Incident Reports, MedLine Supplies Record. At approximately 11:15AM, LPA conducted a physical plant tour. Between 12:05PM – 1:45PM, LPA interviewed the Executive Director and Wellness Director.

(Continue at 9099C)

Unsubstantiated

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: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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-20230620084658

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: 06/23/2023

NARRATIVE

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(Continuation from 9099)

Facility has shortage of incontinent supply
Upon inspection, LPA observed facility does have enough gloves, wipes and diapers for residents. Staff interviewed revealed that facility receives incontinent supply every other week from MedLine Inc.

Based on inspection, observation, and interviews there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No deficiency issued during today's visit.
Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

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