197610403-2-20-2024-31-AS-TAGD-D3JNDY-20240320102304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610403
Report Date: 02/20/2024
Date Signed: 02/20/2024 02:16:03 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/12/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240212161217

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: 106	DATE:	02/20/2024
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Adam Syncheff		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff do not prevent resident from spitting on surfaces in common areas.

INVESTIGATION FINDINGS:

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On 02/20/24, at 09:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by the Executive Director-Adam Syncheff. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, interviews and deliver findings for this complaint.

The investigation consists of the following: On 02/20/24 at 09:25am, LPA Saucedo asked for the census, resident, and staff roster. At 09:46am, LPA Saucedo conducted the physical tour. During the tour, ten (10) residents and six (6) staff were interviewed.

LIC 9099C-continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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-20240212161217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS LA	FACILITY NUMBER: 197610403
	VISIT DATE: 02/20/2024

NARRATIVE

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Regarding the allegation: Staff do not prevent resident from spitting on surfaces in common areas. It is being alleged that Resident #1 (R1) is spitting on the floors in the hallway, lobby and the dining room table, and facility staff are not doing anything to stop R1 from such behavior. During the tour, ten (10) residents and six (6) staff were interviewed. Nine (9) out of ten (10) residents confirmed that R1 does spit around the dining room table where they have breakfast, lunch and dinner. Moreover, R1 spits on napkins and tosses the napkins in the bowls where the residents are eating from. In addition, R1 spits inside the bowls if there is no napkins available. Furthermore, the residents also have seen R1 spit on the floor inside the lobby and outside lobby area. Interviews with six (6) out of six (6) staff members, also confirmed that R1 spit in the dining room area while eating. However, one (1) out of six (6) staff members informed LPA that when the facility staff members attempts to redirect and or communicate with R1, R1 behavior immediately changes and R1 starts screaming and speaking in their native language. The medical technician staff and the Memory Care Director confirmed that when they see R1 spitting they try to redirect R1 or give R1 a cup to spit in. Although the interview with the Executive Director revealed that R1 had been constantly reminded that they have an unacceptable behavior and it has to stop, R1 ignored and continued with this behavior due to language barrier. R1's facility file record review revealed that R1 is ambulatory and has no mental issues. Therefore, based on the LPA's interviews and record review the above allegation(s) above is Substantiated at this time.

An exit interview was conducted, one citation was issued for the above allegation(s) on the LIC 9099-D, and a copy of this report was given to the executive director with the appeal rights.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240212161217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS LA	FACILITY NUMBER: 197610403
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/07/2024 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	87303 (a)(1)The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee/admnistrator agreed to schedule an appointment with R1's doctor and show documentation of what is going to be done to resolve this problem. POC due date: 03/07/24.
	8 9 10 11 12 13 14	Based on the LPA's interviews the licensee/administrator did not ensure one out of one resident at the facility to be clean and sanitary at all times which poses an potential Health, Safety or Personal Rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC9099 (FAS) - (06/04)

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