198320184-2-21-2025-11-AS-JHAD-DEF25Q-20250303160554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 02/21/2025
Date Signed: 02/21/2025 10:25:45 AM

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
02/03/2025 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20250203145625

FACILITY NAME:	AVENIR MEMORY CARE WESTSIDE		FACILITY NUMBER:	198320184
ADMINISTRATOR:	JODI KANOWITZ		FACILITY TYPE:	740
ADDRESS:	7501 OSAGE AVE		TELEPHONE:	(424) 282-0040
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	88	CENSUS: 52	DATE:	02/21/2025
		UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Terri Weitzman Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff handled resident in a rough manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/21/25 at 9:30 am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation above. LPA met with Executive Director Terri Weitzman as the purpose of the visit was explained.

The complaint consisted of the following: On 02/12/25 LPA obtained copies of the following: staff and resident rosters, Resident #1 (R1), facesheet, Physicians report dated 01/30/24, resident assessment, service plan dated 02/02/24, admission agreement dated 01/30/24, physician’s orders, and contact info for 1 heart staffing agency. On 02/12/25 at 9:40 am LPA interviewed staff #2 (S2), between10am-11am LPA conducted interviews with staff #3-6 (S3-S6), and between 11am-12:25 pm LPA conducted interviews with residents #1-5 (R1-R5). On 02/12/25 at 12:45pm LPA conducted telephone interview with S1.
The investigation revealed the following:
Allegation: Facility staff handled resident in a rough manner.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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 3

Control Number 11-AS-20250203145625

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: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 02/21/2025

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

It is being alleged that a caregiver assaulted resident after caregiver was assaulted by resident.

On 02/12/25 at 9:40 am LPA conducted interview with S2 regarding the allegation above, S2 confirmed the allegation above and state it was reported that S1 was protecting self from R1. Per S2, S1 was asked to leave the facility when the incident was reported. On 02/12/25 from 10am-11am LPA conducted interview with S3-S6 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above, 2 of 4 staff interviewed stated residents have reported the above allegation in the past and the allegation was reported to supervisor right away. On 02/12/25 at 11am LPA conducted interview with witness #1 (W1) regarding the allegation above. Per W1, W1 was notified of the allegation above by Avenir Memory Care at Westside. W1 reports there have not been any similar situations in the past with S1, however S1 will not return to Avenir Memory Care at Westside. On 02/12/25 from 11: 15 am-12:25pm LPA conducted interviews with residents #2-5 (R2-R5), 4 of 4 residents interviewed denied the allegation above and reported feeling safe at Avenir Memory Care at Westside. On 02/12/25 LPA was unable to interview resident #1 (R1) due to communication barriers. On 02/12/25 at 12:30pm LPA conducted interview with witness #2 (W2) regarding the allegation above, per W2 W2 was made aware of the incident right away, W2 continues to report there are no health or safety concerns regarding R1's care. On 02/12/25 at 12:45pm LPA conducted telephone interview with S1 regarding the allegation above, S1 confirmed the allegation above however per S1 the allegation was not intentional, as S1 was attempting to protect self. On 02/12/25 LPA reviewed unusual incident report regarding the allegation above, unusual incident report was submitted to the department on 02/07/25.

Based on LPAs observations and interviews which were conducted record review(s), 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, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250203145625

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: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/07/2025 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...Based on observation the licensee did not comply	1 2 3 4 5 6 7	Facility to ensure all staff is trained on personal rights, training to be done yearly and to be documented. Facility to submit a plan on how facility will ensure agency staff has required training for facilities population. Facility to submit plan to LPA by POC due date
	8 9 10 11 12 13 14	with the section cited above as S1 confirmed grabbing R1's hands and resulted in a fall which poses/posed a potential health, safety or personal rights risk to persons in care.	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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3