197610403-12-28-2023-31-AS-NMAN-D2EUKV-20240213143945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610403
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:41:56 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
12/19/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20231219140004

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: 100	DATE:	12/28/2023
		ANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Adam Syncheff		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Abeye Duguma and Christopher Alemoh conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Executive Director, Adam Syncheff, and explained the reason for the visit.

--- Staff unlawfully evicted a resident.

It was alleged that facility refused to take Resident #1 (R1) back. To investigate the allegation, on 12/28/2023 LPA requested records at 10:00 AM and interviewed three (03) staff from 10:30 AM – 12:00 PM. The facility’s Functional Capability Assessment records stated that R1’s needs would not be safely met, R1 has a history of violence, and that resident requires close supervision for medication management and mental health observations.

(CONT on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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-20231219140004

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: 12/28/2023

NARRATIVE

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During interviews with staff, all staff stated R1 is currently in a mental health facility after physically assaulting staff and that, based on R1’s preliminary assessment, R1 will not be readmitted to the facility at this time as they pose an immediate danger to self and others.

Based on interviews 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 noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

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