<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204494
Report Date: 05/02/2022
Date Signed: 05/03/2022 06:27:23 AM

Substantiated


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
04/27/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220427164524
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: 34DATE:
05/02/2022
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:REMON PAGELS TIME COMPLETED:
05:59 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/02/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Executive Director, Remon Pagels, and Community Business Director, Amy Berggreen. LPA explained the purpose of today's inspection visit and to collect information regarding the allegation mentoned above.

The investigation consisted of the following: A review of the roster for residents and staff. A review of resident #1, #2, and #4 (R1-R4) service records and other pertinent documents associated with this complaint.. Interviews with staff #1-#5 (S1-S5), residents #1-#4 (R1-R4), and witness #1-#2 (W1-W2) A tour of the entire facility was inspected.

Evaluation Report continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
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 6
Control Number 11-AS-20220427164524
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: 05/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Illegal eviction.

The details of the complaint state resident #1 (R1) was served with a 30-Day Notice to Terminate. The complainant contacted the Department and claims that (R1) is not treated fairly and that the staff does not like (R1). The complainant states (R1) is accused of having a physical altercation with another resident and that is the reason for the illegal eviction. An interview with (R1) states she was served with an eviction notice, and this is not the first time. (R1) states a prior 30-Day Notice to Terminate was issued in October 2021. An interview with staff #1-#5 (S1-S5) all confirmed that a 30-Day Notice to Terminate was served to (R1) on 03/15/22. The 30-Day Notice to Terminate, Proof of Service of 30-Day Notice to Pay or Quit were sent to (R1), (R1's) family representative, Long Term Ombudsman, and Community Care Licensing (CCLD). The documents were sent by facsimile to (CCLD) on 03/16/22 with an incorrect fax number. The El Segundo Regional (CCLD) did not receive these documents. The facility failed to follow up with (CCLD) for approval as written in Title 22 Regulations Section 87224 Eviction Procedures. The Department contacted the facility on 04/28/22 and spoke with the acting Executive Director and was informed that a Notice to Terminate was issued to (R1) on 03/16/22. It was determined the notice is not valid. Based on interviews and record reviews, there is sufficient evidence to support the allegation mentioned above.

Based on interviews and record review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), The Department observed the following deficiency and issued a citation.

An exit interview was conducted with Remon Pagels, and a hard copy was provided with signature and Appeal Rights.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20220427164524
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: 05/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2022
Section Cited
CCR
87224(b)
1
2
3
4
5
6
7
87224(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety... mental and/or physical health or safety of others in the facility.
1
2
3
4
5
6
7
Executive Director is to review Title 22 Regulaiton Section 87244, and resubmit a 30-Day Notice to Terminate for RO approval by POC 05/11/22.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:Based on interviews and record reviews. The facility failed to properly inform CCLD of the 30-Day Notice to Terminate on 03/15/22. The notice is not valid unless CCLD approves. This violation posed a potential health risks to residents in care.
8
9
10
11
12
13
14
This violation is corrected on visit 05/02/22. The facility resubmitted a new 30-Day Notice to Terminate. A hard copy was given to LPA and original was faxed on 04/29/22.
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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/27/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220427164524

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: 34DATE:
05/02/2022
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:REMON PAGELS TIME COMPLETED:
05:59 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained an injury while in care.
Resident sustained UTI while in care.
Staff failed to meet resident’s needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/02/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Executive Director, Remon Pagels, and Community Business Director, Amy Berggreen. LPA explained the purpose of today's inspection visit and to collect information regarding the allegations mentoned above.

The investigation consisted of the following: A review of the roster for residents and staff. A review of resident #1, #2, and #4 (R1-R4) service records and other pertinent documents associated with this complaint. Interviews with staff #1-#5 (S1-S5), residents #1-#4 (R1-R4), and witness #1-#2 (W1-W2) A tour of the entire facility was inspected.

Evaluation Report continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20220427164524
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: 05/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident sustained an injury while in care.
It is alleged resident #1 (R1) sustained an injury while in care. The complainant claims (R1) sustained injuries on her left ankle. The complainant can not recall the date and time when it happened. The complainant was not present when the incident took place between (R1) and another female resident. An interview with (R1) claims it happened several years back in the Parlor room. (R1) is uncertain of the date and time. (R1) confirms she suffered injuries to her left ankle. (R1) claims there were no witnesses and the other female resident is no longer at the facility. Interviews with residents #2 and #3 (R2-R3) state they were made aware of the incident that had happened but did not have the privilege of any of the information. Interviews with staff #2-#5 (S2-S5) all verified that an incident between (R1) and another female resident had happened, however, no injuries were sustained. (S4-S5) both who knew the incident state (R1) is not the victim and was the one who instigated the incident. An interview with (S3-S4) claims the facility does not have cameras in common areas. Interviews with (R2-R3) and witness #2 (W2) all verified that (R1) has a history of creating problems with other residents and staff and will often time ignore the facility's house rules. Based on the information collected, there is no evidence to support the allegation mentioned above.

Allegation: Resident sustained UTI while in care.
It is alleged that resident #1 (R1) sustained UTI while in care at this facility. The complainant states that (R1) went to seek medical attention in March 2022, and it was revealed that (R1) had Urinary Tract Infection and it is caused by neglect of (R1's) care. However, the complainant contradicts her accusation, when she states that she has no issues with the care staff at this facility and praises them for their services. An interview with (R1) reveals it is common for elderly people to have UTIs. (R1) states she had a history of UTI about 50 years back and did not see it as a problem. A review of a current (R1's) physician's report dated 03/07/22 indicates (R1) can provide self-care. (R1) does not need assistance with toileting and does not wear adult diapers. Interviews with (S1-S5) all verify (R1) is cared for seven (7) days a week by a third-party home care services between 6 am - 2 pm paid by (R1's) family. An interview with staff #3 (S3) states it was under recommendation for the family member to have (R1) examined for UTI as she now exudes some behavior changes in condition. Witness #1 (W1) and (S3) confirmed (R1) did not have prior health issues that are the main causes of UTI. Interviews with (R2-R3) and (R1-R3) all claim that the care has never been an issue and that caregivers are attentive and responsive. Based on the information collected, there is no evidence to support the allegation mentioned above.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20220427164524
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: 05/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff failed to meet residents’ needs.
The details of the complaint state staff failed to meet the resident's needs. According to the complainant, it is not the care that is the issue, (R1) is not granted dignity and respect at this facility. Interviews with (R1-R3) reported the staff is kind and respectful to all the residents. Interviews with (S1-S5) dispute this claim and state staff have mandated training on how to address residents' needs. (S1-S5) all verified that it is (R1) who is critical and will often cause attention to oneself with other residents. An interview with (R1) did not have comments to add and stated that the management staff has been unkind. (R1) did not have specific dates, times, and a witness who could collaborate on her statement. An interview with (W2) states she has observed the staff at this facility grants(R1) dignity and respect. Based on the information collected, there is no evidence to support the allegation mentioned above.

Based on information gathered, an inspection of the facility, observation, analysis of service records, and interviews conducted, the Department found no evidence to support the allegations listed on this complaint report.

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 with Remon Pagels and a copy of the report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6