198320184-8-30-2023-11-AS-MVAO-CWKUZH-20231013160133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 04/26/2023
Date Signed: 08/30/2023 10:48:16 AM

Substantiated

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
04/17/2023 and conducted by Evaluator Wendy Gibbs

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230417172233

FACILITY NAME:	AVENIR MEMORY CARE WESTSIDE		FACILITY NUMBER:	198320184
ADMINISTRATOR:	DRINKHOUSE-QUINTA, MARISSA		FACILITY TYPE:	740
ADDRESS:	7501 OSAGE AVE		TELEPHONE:	(424) 282-0040
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	88	CENSUS: 33	DATE:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jodi Kanowitz		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not prevent resident from being assulted 2 times while in care.

INVESTIGATION FINDINGS:

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On 08/30/23, Licensing Program Analyst (LPA), Mario Leon delivered an amended LIC9099 for the facility listed above. LPA Leon met with Administrator Jodi Kanowitz and explained the purpose of today’s visit.

The investigation consisted of the following:
On 04/26/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced 10-day complaint visit. LPA Gibbs met with Executive Director, Jodi Kanowitz and explained the purpose of today’s visit.

The investigation on 04/23/23 included a tour of the facility, document review, staff interview and video review. LPA received a copy of the staff and resident roster, needs and service plan for R1 and R2, preplacement appraisal for R1 and R2, Physicians report for R1 and R2, medication list for R1 and R2, previous incident reports involving R1 and R2, and staff notes from both of the incidents. LPA interviewed Executive Director, Staff #1-5, Resident’s #1-4, and reporting party. LPA viewed the video of the incident and video of staff at the time of incident.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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-20230417172233

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: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 04/26/2023

NARRATIVE

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Allegation: Staff did not prevent resident from being assaulted two (2) times while in care

The reporting party stated that R1 has been assaulted by R2 two (2) times in the past four (4) months. Reporting party stated the family was informed by the facility that R2 was going to be separated from R1. Additionally, reporting party stated that the family was informed that precautions were going to be in place to ensure another incident didn’t occur.

The investigation reveals that a resident, R2, assaulted another resident, R1, after more than once entering or attempting to enter R2’s room. The facility assured the families that staff would closely supervise R1 and R2. In the last incident, R1 was again assaulted by R2 which led to R1 being hospitalized. R2 believed that R1 was attempting to break into their room again. LPA reviewed video of the incident and video of the staff during the time of the incident, LPA saw that S1 was not monitoring R1 as they walked back to their room to ensure they found the correct room. LPA conducted a file review for R1 that states R1, for mobility, requires assistance due to poor eyesight. Additionally, R1’s cognitive needs states R1 requires re-direction to their room or to activities due to a history of R1 entering other resident’s rooms.

Based on LPAs observations and interviews which were conducted and record review(s), 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 & Chapter 8) are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator, Jodi Kanowitz, and a copy of this report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230417172233

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: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/26/2023 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2)Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of	1 2 3 4 5 6 7	Executive Director has taken measures to seperate residents, R2 has moved to a different room away from R1. Additionaly, Executive Director has offered a one-on-one caregiver for R1 upon return to the facility for a week. R2 was recommended for a psych evaluation.
	8 9 10 11 12 13 14	toxic materials. This requirement is not met as evidenced by: Based on record reviews, observations and interviews, the licensee did not comply with the section cited above. The staff did not ensure the resident was safe from wandering and aggressie behavior.	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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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