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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204494
Report Date: 01/12/2022
Date Signed: 01/12/2022 04:12:01 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20211025115141
FACILITY NAME:ATRIA PARK OF PACIFIC PALISADESFACILITY NUMBER:
198204494
ADMINISTRATOR:BRIAN LARIOSFACILITY TYPE:
740
ADDRESS:15441 W SUNSET BLVDTELEPHONE:
(310) 573-9545
CITY:PACIFIC PALISADESSTATE: CAZIP CODE:
90272
CAPACITY:60CENSUS: DATE:
01/12/2022
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Vladimir KaplanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Residents not being changed timely
Staff are not following residents dietary requirements
Residents hygiene needs are not being met
Residents are not being showered timely
Facility does not have activities for residents
Insufficient staffing
Residents are not being fed timely
INVESTIGATION FINDINGS:
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On 1/12/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Executive Director Vladimir Kaplam. 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 11/3/2021 LPA toured facility grounds and interviewed Executive Director Adrienne Craig Aziz. LPA reviewed documents in association with the allegations. On 12/14/2021 LPA Cifuentes interviewed staff 1-staff 6 (S1-S6), residents 1-resident 6 (R1-R6) and 2 witnesses (W1 and W2).

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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 8
Control Number 11-AS-20211025115141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494
VISIT DATE: 01/12/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Residents not being changed timely

The complainant alleges that R1 has been found several times with soiled briefs and no staff are available to change them. Per Executive Director Adrienne Craig Aziz, residents are checked every two hours. LPA spoke with residents (R1-R6) regarding the allegations. All six residents stated they use the restroom on their own and do not need assistance. Several of the residents spoken to reside in the memory care unit, and due to diagnosis, might have misunderstood the questions. LPA spoke with staff 1-6 regarding allegations. Of the staff questioned, 6 out of 6 stated the residents are changed ever 2 hours.

Based on information gathered, the department did not find sufficient evidence to support allegation " Residents not being changed timely”

Allegation: Staff are not following residents’ dietary requirements

The complainant alleges that R1 was fed items that are restricted on their diet. LPA spoke with Executive Director Adrienne Craig the allegation. Per Director Craig-Aziz, facility is able to accommodate all dietary needs and dietary requirements are in the kitchen. Residents sometimes request items that are not on their dietary lists and if the requirements are not due to a dietary restriction by doctor, we give them what they ask for. LPA reviewed documents for R1, which shows they are not on a medically restricted diet. LPA interviewed residents regarding allegation and of the 6 residents interviewed 5 stated facility was able to accommodate their dietary requirements. Of the staff interviewed, 6 out of 6 stated the facility was able to and had accommodated a wide variety of diets, and also added that residents occasionally requested items that were not part of their dietary requirements and that staff complied.

Based on information gathered, the department did not find sufficient evidence to support allegation “Staff are not following residents’ dietary requirements.”

Continued on 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20211025115141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494
VISIT DATE: 01/12/2022
NARRATIVE
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Allegation: Residents hygiene needs are not being met

The complainant alleges that R1 and other residents have been found wearing the same clothing as the previous day or are improperly dressed. The complainant also alleged that facility staff are not brushing residents’ teeth. LPA spoke with residents (R1-R6) regarding the allegations. Due to diagnosis, four of those interviewed might have misunderstood the questions, but all 6 of those interviewed stated their hygiene needs are being met whether through their own efforts or those of the staff. LPA interviewed S1-S6 regarding allegation. Of the 6 interviewed, all 6 stated that resident hygiene needs are being met. Residents teeth are brushed daily and all residents are dressed in clean clothing at least once a day if not more often.

Based on information gathered, the department did not find sufficient evidence to support allegation " Residents hygiene needs are not being met

Allegation: Residents are not being showered timely

The complainant alleges that facility residents are not being bathed regularly. Per facility administrator Adrienne Craig-Aziz, residents are showered at least twice a week but can receive more showers as requested and it is outlined in their care plans. LPA spoke with residents (R1-R6) regarding showers. Due to diagnosis, four of those interviewed might have misunderstood the questions, but 6 out of 6 resident stated they shower on their own or with some assistance and they are getting regular showers. Of the staff questioned, 6 out of 6 stated residents are bathed weekly per schedule, with small changes to the schedule due to residents requesting to shower at a later time/date.

Based on information gathered, the department did find sufficient evidence to support allegation " Residents are not being showered timely”

Continued on 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20211025115141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494
VISIT DATE: 01/12/2022
NARRATIVE
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Allegation: Facility does not have activities for residents

The complainant alleges that there are no activities for the memory care residents. LPA Cifuentes spoke to administrator regarding allegation. Per Ms. Craig Azziz the facility has everything from physical fitness, play games, puzzles, coloring, painting. Other activities are facility wide and announced to memory care that the activity will be in the communal area or if there are outings, like to Mel’s dinner, people from the entire facility are invited. LPA spoke with residents (R1-R6) regarding the allegation. Due to diagnosis, four of those interviewed might have misunderstood the questions, but all 6 residents stated the facility has activities. Of those 6, four stated they participated and 2 stated they did not participate. LPA interviewed staff and of those interviewed 6 out of 6 stated facility has a variety of activities for memory care residents.



Based on information gathered, the department did find sufficient evidence to support allegation " Facility does not have activities for residents”

Allegation: Insufficient staffing

The complainant alleges that on October 24, 2021, at least two residents did not receive their morning meds due to insufficient staff. This allegation was recently investigated in complaint 11-AS-20211025121323. As both complaints reference the same incident, and allegation was already substantiated, LPA Cifuentes is unsubstantiating the allegation on this complaint.

Based on information gathered, the department did not find sufficient evidence to support allegation " Insufficient staffing

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20211025115141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494
VISIT DATE: 01/12/2022
NARRATIVE
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Allegation: Residents are not being fed timely

The complainant alleges that R2 was chewing on a cord as they had not been fed. LPA spoke with administrator Adrienne Craig-Aziz regarding allegation. She stated that meals are delivered to the third floor at 8am, 11:30am and 4:30 pm like clockwork, it is very rarely late and if so it is not more than 15 minutes. LPA spoke with residents (R1-R6) regarding the allegation. Due to diagnosis, four of those interviewed might have misunderstood the questions, but all 6 of those interviewed stated food was received timely with no issues.


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Based on information gathered, the department did not find sufficient evidence to support allegation " Residents are not being fed timely”

The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: " Residents not being changed timely”, “Staff are not following residents dietary requirements”, “Residents hygiene needs are not being met”, “Residents are not being showered timely”, “Facility does not have activities for residents”, “Insufficient staffing”, “Residents are not being fed timely.”



Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099's were provided to Executive Director Vladimir Kaplan.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20211025115141

FACILITY NAME:ATRIA PARK OF PACIFIC PALISADESFACILITY NUMBER:
198204494
ADMINISTRATOR:BRIAN LARIOSFACILITY TYPE:
740
ADDRESS:15441 W SUNSET BLVDTELEPHONE:
(310) 573-9545
CITY:PACIFIC PALISADESSTATE: CAZIP CODE:
90272
CAPACITY:60CENSUS: DATE:
01/12/2022
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Vladimir KaplanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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2
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9
Staff not adequately supervising resident resulting in resident sucking on a window blind cord
INVESTIGATION FINDINGS:
1
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10
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13
On 1/12/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Executive Director Vladimir Kaplan. 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 11/3/2021 LPA toured facility grounds and interviewed Executive Director Adrienne Craig Aziz. LPA reviewed documents in association with the allegations. On 12/14/2021 LPA Cifuentes interviewed staff 1-staff 6 (S1-S6), residents 1-resident 6 (R1-R6) and 2 witnesses (W1 and W2).

Continued on 9099-c
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20211025115141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494
VISIT DATE: 01/12/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff not adequately supervising resident resulting in resident sucking on a window blind cord
The complainant alleges that on October 24, 2021, they found R2 chewing on the end of a window blind cord for at least thirty minutes and no staff were present. LPA spoke to Executive Director Adrienne Craig Aziz, who confirmed that R2 was found chewing on the end of a window blind cord on 10/24/2021. Per Ms. Craig Aziz, this is due to residents medical condition. LPA spoke with residents (R1-R6) regarding the allegation. Out of those interviewed 1 out of 6 saw another resident chewing on a window blind cord. LPA spoke with S1-S6 regarding allegation. Of those interviewed, 2 out of 6 stated there was a resident who like to put non-edible items in there mouth.

Based on information gathered, the department did find sufficient evidence to support allegation " Staff not adequately supervising resident resulting in resident sucking on a window blind cord

Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.



An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Executive Director Vladimir Kaplan.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20211025115141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2022
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidenced by:
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Licensee will provide a plan to LPA to ensure adequate supervision and redirection as needed by POC due date. POC cleared during visit on 1/12/2022.
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Based on interviews, LPA Cifuentes found that R2 had been left unsupervised and tried to consume an inedible item. This posses a potential health and safety issue for residents in care.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8