198204494-5-17-2023-11-AS-EMAZ-CTWLGP-20230720084501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204494
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:03:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2022 and conducted by Evaluator Martessa Brown

COMPLAINT CONTROL NUMBER: 11-AS-20220527135834

FACILITY NAME:	ATRIA PARK OF PACIFIC PALISADES		FACILITY NUMBER:	198204494
ADMINISTRATOR:	BRIAN LARIOS		FACILITY TYPE:	740
ADDRESS:	15441 W SUNSET BLVD		TELEPHONE:	(310) 573-9545
CITY:	PACIFIC PALISADES	STATE: CA	ZIP CODE:	90272
CAPACITY:	60	CENSUS: 36	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	10:51 AM
MET WITH:	Remon Pagels		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Residents are not provided adequate supervision.
Resident's dietary needs are not being followed.
Facility has pests.
Hazardous cord hanging from window.

INVESTIGATION FINDINGS:

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On 5/17/2023 Licensing Program Analyst (LPA Martessa Brown conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Executive Director Raymond Pagels. LPA explained the purposed of the visit was to deliver findings regarding the allegations listed above and was grated entry.

The investigation consisted of the following: On 5/6/22 LPA toured the facility and interviewed Executive Director Reymond Pagels. LPA obtained LPA reviewed documents in association with the allegations. On 5/6/22 LPA Brown interviewed staff S1-S3 (S1-S3). On 5/17/23, LPA toured the facility and interviewed staff (S4-S5) and Residents (R2-R4).

Continued on 9099-C

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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 11-AS-20220527135834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES	FACILITY NUMBER: 198204494
	VISIT DATE: 05/17/2023

NARRATIVE

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Regarding the allegation: residents are not provided adequate supervision. It was alleged that there is not adequate supervision for residents in the facility. LPA toured the facility on 5/6/22 and 5/17/23. LPA observed 3 Residents Service Assistance in memory care unit (RSA). LPA observed kitchen area located adjacent to the dining room section off. LPA did not observed resident without adequate supervision. LPA conducted interviews on 5/17/23 with 2-R4 and all residents stated they have no concern with the supervisor at the facility and have not heard any complaints. Interviews conducted on 5/6/22 and 5/17/23, Administrator and staff S1-S5 stated there is 3 RSA in memory care unit and did not hear of any concern with no supervisor. Above allegation is unsubstantiated.

Regarding the allegation: Resident's dietary needs are not being followed. It was alleged that dietary needs are not being followed. LPA toured the facility on 5/6/22 and 5/17/23. LPA observed face sheet/ dietary board and binder for residents located in the main kitchen. LPA also observed face sheet/Dietary binder for residents in mc unit. Interviews conducted on 5/6/22 and 5/17/23, staff S1-S5 stated residents dietary needs are followed and checked before they are served. LPA Interview Administrator LPA R1 request bacon was given a piece of bacon but did not consume it. Interview R2-R4 stated they had no diet restrictions. LPA reviewed R1 physician report and indicated R1 was a vegetarian. Factsheet indicated resident was on a regular diet. Information from W1 stated R1 was a pescatarian. Based on records review and documents it was unclear on R1 dietary needs the above allegation is unsubstantiated.

Regarding the allegation: Facility has pests. It was alleged the facility has roaches. LPA toured the facility on 5/6/22 and 5/17/23. LPA did not observe any pest in the facility. LPA conducted interviews on 5/17/23 with 2-R4 and all residents stated they have not seen any roaches in the facilty and had no concern. Interviews conducted on 5/6/22 and 5/17/23, Administrator and staff S1-S5 stated they have not seen any roaches in the facility and pest control comes once a month. The above allegation is unsubstantiated.

Regarding the allegation: Hazardous cord hanging from the window. It was alleged the facility has a hazard chocking cord. LPA toured the facility on 5/6/22 and 5/17/23. LPA did not observe any hazard choaking cord hanging from the window. LPA conducted interviews on 5/17/23 with R2-R4 and all residents stated they haven’t heard any concerns with any item being hazardous. Interviews conducted on 5/6/22 and 5/17/23, Administrator and staff S1-S5 stated there is no hazard cord hanging from the window and did not have concerns. The above allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit report conducted and report was provided to Remon Pagle

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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