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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 03/21/2023
Date Signed: 03/21/2023 05:00:41 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
03/17/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230317100206
FACILITY NAME:GARDEN OF PALMSFACILITY NUMBER:
197609826
ADMINISTRATOR:GINSBURG, MENACHEMFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:130CENSUS: 64DATE:
03/21/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nirjara Acharya, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not report incident to CCL.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA arrived at 10:30 AM. Upon entry, LPA met with the Executive Director, Nirjara Acharya, and explained the reason for the visit.

---Staff did not report incident to CCL.

It was alleged that facility did not file an incident report for a recent incident that took place involving Resident (#1). To investigate the allegation, on 03/21/2023 at 11:30 AM, LPA interviewed four (04) staff and at 1:00 PM reviewed documents. During interviews with staff, all staff confirmed that an incident took place that involved R1 breaking a television and subsequent aggressive behavior towards self and not others. Record review revealed that the facility did not report the incident to the Department.

(CONT. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
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 5
Control Number 31-AS-20230317100206
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: 03/21/2023
NARRATIVE
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Based on interviews and record review, there is enough information to verify the allegation. Therefore, the 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 LIC 9099-D):

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230317100206
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: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/23/2023
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements (a)..licensee shall furnish to the agency such reports as the Dept. may require, including, but not limited to, the following:(1)..report shall be submitted to the..agency..within seven days of the occurrence..(D) Any incident which threatens the welfare, safety or health of any resident..
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The Executive Director will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87211 Reporting Requirements; The written letter must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by; Based on record reviews and interview, the facility did not report R1’s aggressive behavior to the Dept. which poses a potential Health and Safety risk to resident 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: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/17/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230317100206

FACILITY NAME:GARDEN OF PALMSFACILITY NUMBER:
197609826
ADMINISTRATOR:GINSBURG, MENACHEMFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:130CENSUS: 64DATE:
03/21/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nirjara Acharya, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident engaged in physical altercations with other residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA arrived at 10:30 AM. Upon entry, LPA met with the Executive Director, Nirjara Acharya, and explained the reason for the visit.

--- Resident engaged in physical altercations with other residents in care.

It was alleged that Resident #1 was physically aggressive with other residents. To investigate the allegation, on 03/21/2023 at 11:30 AM, LPA interviewed four (04) staff and six (06) residents and at 1:00 PM reviewed documents. During interviews with staff, Staff #2 (S2) and Staff #4 (S4) stated that Resident #1 (R1) was seen pacing in the hallway and was upset with herself but never got physically aggressive with others nor does R1 have a history of such behavior towards others.

(CONT. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230317100206
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: 03/21/2023
NARRATIVE
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Staff #1 (S1) and Staff #3 (S3) both stated that they did not see the incident, but that it was reported to them that R1 broke the television and was pacing the hallways. During interviews with all residents, LPA terminated Memory Care interviews. Record review states that R1 does not have inappropriate or aggressive behavior and file review shows that R1 does not have a history of incidents involving aggression with other residents.

Based on the information revealed from the interview and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5