197610403-9-18-2023-31-AS-MVAO-D223C4-20240131170719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610403
Report Date: 09/18/2023
Date Signed: 09/18/2023 02:53:27 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
09/14/2023 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20230914091117

FACILITY NAME:	GARDEN OF PALMS LA		FACILITY NUMBER:	197610403
ADMINISTRATOR:	HIRSCH,RENA		FACILITY TYPE:	740
ADDRESS:	1025 N FAIRFAX AVE		TELEPHONE:	(323) 656-7900
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	130	CENSUS: 99	DATE:	09/18/2023
		UNANNOUNCED	TIME BEGAN:	11:48 AM
MET WITH:	Nijara Acharya, Jessica Perez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are mismanaging resident medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that Resident 1 (R1) was not provided their pain medication for approximately three days. LPA met with the Regional Administrator, Nijara Acharya, and Wellness Director, Jessica Perez, and advised them of the complaint. Today's investigation consisted of staff and resident interviews and a review of resident records.

According to the Wellness Director, facility was waiting for the doctor verfication with the pharmacy, in order for R1's Percocet to be refilled. R1 was advised of this, and understood that this brand of medication requires doctor approval before it can be refilled. R1's Percocet was requested for refill on 09/12/23, and phamacy refilled on 09/14/23 and provided to R1 as prescribed.

Interview with R1 confirmed their allegation. R1 also confirmed that it was explained to them that

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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-20230914091117

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 LA	FACILITY NUMBER: 197610403
	VISIT DATE: 09/18/2023

NARRATIVE

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their doctor needed to authorize their Percocet before pharmacy can continue to refill. R1 stated they got their refill on 09/14/23. In addition, interviews with random residents were conducted, and these residents ten (10) of ten, did not express any complaint or concern of their medication and medication refill.

In addition to interviews, LPA made a record review of R1's records to confirm facility's request for R1's refill prescription, and confirmation that communication for the refill was requested on 09/12/23, and completed and delivered by the pharmacy on 09/14/23.

Based on the information obtained, it could not be proven that staff mismanaged R1's medication. Therefore the allegation is deemed Unsubstantiated at this time. Regional Administrator advised, and a copy of this report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC9099 (FAS) - (06/04)

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