198320184-10-26-2022-11-AS-MVAO-CMBVT5-20221221154235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:34:33 PM

Unsubstantiated

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
10/21/2022 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20221021133921

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: 24	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	JODI KANOWITZ		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility did not maintain an accurate record for resident while in care.

INVESTIGATION FINDINGS:

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On 10/26/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced 10-day complaint visit at this facility. Upon arrival, LPA called the facility to conduct a risk assessment. LPA spoke with Administrator Jodi Kanowitz who confirmed the facility is Covid-19 free. LPA met with Administrator Kanowitz and Director of Marketing Ashley Shire and explained the purpose of today's visit.

The investigation consisted of the following: LPA toured the inside and outside grounds of the facility. LPA requested and obtained copies of Resident #1’s (R1) service records: Identification and Emergency Information, Admission Agreement, Physician’s Report, Preplacement Appraisal, Medication Administration Record (MAR) and other pertinent documents related to Resident #1. LPA also obtained a copy of Resident Roster and Staff Roster. LPA interviewed the Administrator (S1) and the Director of Marketing (S2).

REPORT CONTINUED IN LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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-20221021133921

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: 10/26/2022

NARRATIVE

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Investigation consisted of the following.

Allegation: Facility did not maintain an accurate record for resident while in care.

It is alleged that facility did not maintain an accurate record for resident while in care. Based on interview with the Administrator (S1) and the Director of Marketing (S2), R1’s records have been maintained in the facility. S1 and S2 stated R1 was admitted to the facility on 4/23/22 and was discharged on 5/5/2022. Based on the department’s records review, Resident #1’s (R1) service records were maintained in the facility according to section 87506 (Resident Records) of Title 22. LPA reviewed R1’s Identification and Emergency Information, Admission Agreement, Physician’s Report, Preplacement Appraisal, Centrally Stored Medication Destruction Record, Consent form, and other pertinent records indicated in LIC 858 (Resident's Records Review form). Based on LPA’s observations, interviews and records review, there is no sufficient evidence to corroborate the above allegation.

Based on the department’s investigations, there is no sufficient evidence to support the allegation, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

No deficiencies were cited during this visit.

Exit interview conducted and a copy of this report was provided to Administrator Jodi Kanowitz.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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