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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610403
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:41:57 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
09/14/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20230914123412
FACILITY NAME:GARDEN OF PALMS LAFACILITY NUMBER:
197610403
ADMINISTRATOR:HIRSCH,RENAFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:130CENSUS: 100DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Jessica Perez - Wellness DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not addressing residents' health conditions while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with Wellness Director Jessica Perez and explained the reason for the visit.

LPA conducted physical plant tour at 9:50 AM, requested copies of facility documents relevant to the investigation at 10:18 AM and interviewed staff and residents between 10:30 AM to 1:00 PM. It was alleged that Resident #1 (R1) is being treated poorly by the caregiver and R1's health conditions are worsened daily. LPA's record review today at 1:00 PM revealed that R1 was admitted at the facility on 04/20/23 and immediately admitted to Hospice services on the same day of admission at the facility. Further review also revealed that R1 was on Assisted Living Waiver (ALW) and currently on Home Health services. Moreover, the facility had an internal log for all the Hospital visits, Skilled Nursing Facility discharges, Hospice and Home Health agencies visits and caregiver logs for all any unusual incident about R1 including but not limited to R1's refusal to shower, hospitalization and the likes. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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 2
Control Number 31-AS-20230914123412
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 LA
FACILITY NUMBER: 197610403
VISIT DATE: 01/16/2024
NARRATIVE
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(continued from LIC 9099)

LPA's interview with three (3) staff today between 10:30 AM to 1:00 PM revealed that R1 is living with Resident #2 (R2) in the same room, and they always call if they need anything. They are on tray service but always buy their own food delivered to their room. All three (3) staff interviewed denied mistreating and/or treating R1 and R2 poorly. LPA's interview with a total of nine (9) residents on 09/26/23 and three (3) additional residents today between 10:30 AM to 1:00 PM revealed that twelve (12) out of twelve (12) residents interviewed stated that the staff are respectful and provided all the care they need.

Based on the information gathered during today and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2