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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320127
Report Date: 09/18/2024
Date Signed: 09/18/2024 02:06:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20240419164424
FACILITY NAME:WATERMARK AT WESTWOOD VILLAGE, THEFACILITY NUMBER:
198320127
ADMINISTRATOR:LILIT MNATSAKANYANFACILITY TYPE:
740
ADDRESS:947 TIVERTON AVENUETELEPHONE:
(310) 208-4590
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:237CENSUS: 102DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Executive Director Stephanie KoffmanTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Residents pendents are disabled due to transition between new management company.
INVESTIGATION FINDINGS:
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On 09/18/24 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent visit to deliver complaint findings. LPA met with Executive Director (ED) Stephanie Koffman as the purpose of the visit was explained.

The investigation consisted of the following: On 04/25/24 (LPA) Wendy Gibbs conducted initial visit and conducted the following: a tour the facility, pendant test for bedrooms #502 and #608, interviews with staff (S1-S10), and interviews with residents (R1-R4). On 04/25/24 LPA Wendy Gibbs obtained the following documents: staff Roster, resident Roster, email to staff regarding room checks, room check log, death report, needs and service plan, admission evaluation, and physicians report. On 09/18/24 LPA Lizeth Villegas obtained a copy of the staff and resident rosters and conducted a tour, interviews with executive director (ED), and residents #5-10 (R5-R10).

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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 5
Control Number 11-AS-20240419164424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 09/18/2024
NARRATIVE
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Allegation: Residents pendents are disabled due to transition between new management company.

It is being alleged that residents’ pendants and bedroom phones have not been working for 5 days due to change in management companies. On 04/25/24 LPA Wendy Gibbs conducted interviews with staff #1-10 (S1-S10) regarding the allegation above, 9 of 10 staff interviewed confirmed the allegation above and reported the phones and pendants were down for a couple of days. 1 of 10 staff interviewed reported being unaware of the residents’ phones and pendants being down. On 04/25/24 LPA Wendy Gibbs conducted interviews with residents #1-4 (R1-R4) regarding the allegation above, 2 of 4 residents interviewed confirmed pendants were down, 2 of 4 residents interviewed reported being unaware of the pendants being down as the pendants are not used regularly. On 09/18/24 LPA Villegas conducted interview with resident 5-10 (R5-R10) regarding the allegation above, 3 of 6 residents interviewed confirmed pendants were down, 3 of 6 residents interviewed denied the allegation above. On 09/18/24 LPA Villegas conducted interview with executive director (ED) regarding the allegation above, Per ED, ED has no knowledge of the allegation above as ED was employed after the change in management. On 09/18/24 LPA conducted tour of the facility and conducted a pendant test of 3 random pendants, pendant were observed to be operational with response time of 5-8 minutes.

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

Exit interview conducted with Executive Director Stephanie Koffman, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20240419164424

FACILITY NAME:WATERMARK AT WESTWOOD VILLAGE, THEFACILITY NUMBER:
198320127
ADMINISTRATOR:LILIT MNATSAKANYANFACILITY TYPE:
740
ADDRESS:947 TIVERTON AVENUETELEPHONE:
(310) 208-4590
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:237CENSUS: 102DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Executive Director Stephanie KoffmanTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Residents missed meals due to phones not working due to transition between new management company.
INVESTIGATION FINDINGS:
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On 09/18/24 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent visit to deliver complaint findings. LPA met with Executive Director (ED) Stephanie Koffman as the purpose of the visit was explained.

The investigation consisted of the following: On 04/25/24 (LPA) Wendy Gibbs conducted initial visit and conducted the following: a tour the facility, pendant test for bedrooms #502 and 608, interviews with staff (S1-S10), and interviews with residents (R1-R4). On 04/25/24 LPA Wendy Gibbs obtained the following documents: staff Roster, resident Roster, email to staff regarding room checks, room check log, death report, needs and service plan, admission evaluation, and physicians report. On 09/18/24 LPA Lizeth Villegas obtained a copy of the staff and resident rosters and conducted interviews with executive director (ED), and residents #5-10 (R5-R10).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20240419164424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 09/18/2024
NARRATIVE
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Allegation: Residents missed meals due to phones not working due to transition between new management company

It is being alleged that residents were unable to order their meals due to the phones being down. On 04/25/24 LPA Wendy Gibbs conducted interviews with staff #1-10 (S1-S10) regarding the allegation above, 6 of 10 staff interviewed reported being unaware of the allegation above, 2 of 10 staff interviewed denied the allegation above and reported meals were provided to all residents in care, 2 of 10 staff interviewed confirmed the allegation and stated there were residents who reported not receiving a meal. On 04/25/24 LPA Wendy Gibbs conducted interviews with residents #1-4 (R1-R4) regarding the allegation above, 4 of 4 residents interviewed denied the allegation above and reported receiving 3 meals a day. On 09/18/24 LPA Villegas conducted interview with resident 5-10 (R5-R10) regarding the allegation above, 6 of 6 residents interviewed denied the allegation above and reported receiving 3 meals a day. On 09/18/24 LPA Villegas conducted interview with executive director (ED) regarding the allegation above, per ED since ED took over there have been no issues with the facility phones and there have been no reports of any residents missing any meals.

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

Exit interview conducted with Executive Director Stephanie Koffman, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240419164424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
87303(i)(1)(A-C)
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Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more... shall have a signal system which shall: operate from each resident's living unit. transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit
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Deficiency corrected at the time of visit, visit was done on 4/25/24.
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loud enough to summon staff. Identify the specific resident living unit. Based on interviews and records review the facility transition from watermark retirement communities a to integral senior living the signal system was not operation with includes residents pendants, this poses a health and safety
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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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5