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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 11/20/2025
Date Signed: 11/20/2025 12:27:31 PM

Unsubstantiated


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
08/19/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250819130955
FACILITY NAME:AVENIR MEMORY CARE WESTSIDEFACILITY NUMBER:
198320184
ADMINISTRATOR:JODI KANOWITZFACILITY TYPE:
740
ADDRESS:7501 OSAGE AVETELEPHONE:
(424) 282-0040
CITY:LOS ANGELESSTATE: CAZIP CODE:
90045
CAPACITY:88CENSUS: 51DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Ashley Shire/Interim Executive DirectorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not address a resident's change in medical condition.
Staff did not provide adequate care and supervision.
Staff did not properly report incidents involving the residents.
INVESTIGATION FINDINGS:
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On 11/20/2025 at approximately 12:00 pm, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met Ashley Shire/Interim Executive Director. LPA Iniguez explained the purpose of this visit. This report supersedes the report created 8/29/25 and the findings will remain unchanged.

Investigation Consisted of: LPA conducted the following interviews: Executive Director’s Interview (A#1), Witness Interviews(W#1), Residents Interviews (R#1-R#6) and Staff Interview (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 8/27/25, Staff Roster dated: 8/27/25, copy of (R#1)’s face sheet dated: 6/18 24, (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:4/10/25,5/16/24, and 2/6/23, copy of (R#1) Service Plan dated: 2/3/23, copy of (R#1)’s Physician Orders for Life-Sustaining Treatment (POLST) no date, see C page for more details.

Evaluation Report continues LIC 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
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 6
Control Number 11-AS-20250819130955
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: 11/20/2025
NARRATIVE
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This report supersedes the report created 8/29/25 and the findings will remain unchanged.

Investigation Revealed the Following:

Allegation: Staff did not address a resident's change in medical condition

The details of the complaint alleged that (R#1) had fallen approximately 6-7 times in the evenings, and facility staff have not been checking on them.



At approximately 8:00 a.m., Licensing Program Analyst (LPA) Iniguez conducted a review of facility records, including the Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A) for resident (R#1). The LIC 602A was completed annually, with records dated February 6, 2023; May 16, 2024; and most recently, April 10, 2025. Following the completion of the April 10, 2025, LIC 602A, the facility updated (R#1)’s Needs and Services Plan, originally dated February 3, 2023, to reflect the resident’s changing condition. The revised plan outlined specific care strategies and support services tailored to (R#1)’s evolving health needs. This demonstrates the facility’s commitment to aligning care planning with regulatory requirements under Title 22, which emphasizes individualized care and the need to respond to changes in condition, particularly for residents with cognitive impairments. Additionally, LPA Iniguez reviewed (R#1)’s hospice documentation. Records indicated that (R#1) was initially enrolled in hospice services on July 12, 2024, discharged after improvement, and subsequently re-enrolled on July 25, 2025, continuing through their final days.

At approximately 1:00 p.m., during an interview with the Executive Director (A#1), she stated that when (R#1) experienced a fall, the facility immediately notified the resident's physician and addressed her health condition. (R#1) was enrolled in hospice services on two separate occasions while residing at the facility. Additionally, (A#1) referenced Unusual Incident Reports dated February 7, 2024; June 9, 2025; and July 23, 2025, which documented incidents of falls sustained by (R#1). In each instance, facility staff promptly assessed (R#1) and contacted emergency services for further evaluation.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20250819130955
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: 11/20/2025
NARRATIVE
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This report supersedes the report created 8/29/25 and the findings will remain unchanged.

On August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025.


On August 28, 2025, at approximately 2:00 PM, during an interview with residents (R#2-R#6), (5) out of (5) stated that they think the facility will alert their physicians and representatives in case their health condition changes.

On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#5), (5) out of (5) stated that when (R#1) sustained a fall, the facility contacted their physician. The physician will provide us with orders to address any changes in conditions that occur.
Allegation: Staff did not provide adequate care and supervision

The details of the complaint alleged that (R#1) sustained a hand fracture due to the lack of facility staff supervision.



On August 29, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed copies of (R#1)’s monthly facility logs for incontinence check and resident daily activities of daily living (ADL’s) check, LPA Iniguez observed that the facility conducted every day (ADLs) checks on (R#1) from 2023 until 2025. Additionally, the facility conducted nightly incontinence checks every other hour on (R#1) monthly from 2023 until 2025.

At approximately 10:00 a.m., during an interview with the Executive Director (A#1), she stated that (R#1) consistently received adequate care and supervision from the facility staff. Additionally, (A#1) explained that, according to (R#1)’s current Plan of Care, the resident required minimal assistance with transferring and no assistance with mobility. However, (A#1) emphasized that the care team actively monitored for any changes in (R#1)’s condition and conducted reappraisals as needed to ensure that the care remained aligned with (R#1)’s evolving needs.



Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20250819130955
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: 11/20/2025
NARRATIVE
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This report supersedes the report created 8/29/25 and the findings will remain unchanged.

On August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025.



On August 28, 2025, at approximately 2:00 PM, during an interview with residents (R#2-R#6), (5) out of (5) stated that the facility staff provides enough care and supervision for them.

On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#5), (5) out of (5) stated that stated that (R#1) received sufficient care and supervision while at the facility. Staff reported that they followed (R#1)’s Plan of Care and documented any observed changes in the resident’s condition.

Allegation: Staff did not properly report incidents involving the residents

The details of the complaint alleged that facility administrator instructed facility staff not to report (R#1) falls and injuries.



At approximately 9:00 a.m., during review of records, LPA Iniguez observed copies of Unusual Incident Reports (LIC 624) related to resident (R#1). The facility had documented and reported each incident involving (R#1) to the Community Care Licensing Division (CCLD) and the Long-Term Care Ombudsman via fax, in compliance with regulatory requirements. Additionally, LPA Iniguez reviewed the facility’s internal incident reports, which were consistent with the corresponding LIC 624 forms. These reports included detailed descriptions of each incident, the actions taken by staff, and the follow-up measures implemented to ensure resident safety. This documentation demonstrates the facility’s adherence to reporting protocols and its responsiveness to incidents involving (R#1).

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20250819130955
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: 11/20/2025
NARRATIVE
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This report supersedes the report created 8/29/25 and the findings will remain unchanged.

On August 28, 2025, at approximately 10:00 a.m., during an interview with the Executive Director (A#1), the Executive Director stated that the Director of Health Services is responsible for recording and reporting resident incidents. In the case of (R#1), she confirmed that all incidents had been reported to the Community Care Licensing Division (CCLD) and to the resident’s representative. (A#1) denied ever instructing staff not to report incidents, stating that she has always encouraged complete transparency and compliance with reporting requirements. This statement was supported by a review of facility records, which included Unusual Incident Reports (LIC 624) for (R#1) dated 2/9/24, 3/4/24, 6/13/25, 7/31/25, 8/5/25, and 9/16/24, as well as a Death Report (LIC 624A) dated 8/12/25. Additionally, (A#1) stated that internal incident reports dated 7/23/25, 7/24/25, 6/8/25, 6/9/25, 5/15/25, 2/23/25, 11/1/24, and 9/11/24 were reviewed and found to be consistent with the official reports.



On August 28, 2025, at approximately 2:00 p.m., Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025.

On August 28, 2025, at approximately 2:00 p.m., during an interview with residents (R#2-R#6), (5) out of (5) stated that they feel the facility will report to their representatives and physician if something happens to them.

On August 28, 2025, at approximately 1:00 pm, during an interview with facility staff (S#1–S#5), (5) out of (5) stated that (R#1) falls and changes in condition were reported to the physician and to the Community Care Licensing Division (CCLD), and that they were never instructed to withhold such information.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20250819130955
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: 11/20/2025
NARRATIVE
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This report supersedes the report created 8/29/25 and the findings will remain unchanged.

These statements were supported by a review of facility records, which included Unusual Incident Reports (LIC 624) dated 2/9/24, 3/4/24, 6/13/25, 7/31/25, 8/5/25, and 9/16/24, as well as a Death Report (LIC 624A) dated 8/12/25. Internal incident reports dated 7/23/25, 7/24/25, 6/8/25, 6/9/25, 5/15/25, 2/23/25, 11/1/24, and 9/11/24 were also reviewed and found to be consistent with the official reports. Additionally, (5) out of (5) facility staff stated that daily Activities of Daily Living (ADL) logs and bi-hourly incontinence checks from 2023 to 2025 demonstrated that (R#1) received consistent care and supervision. Hospice admission notes dated 7/12/24 and 7/25/25, along with updated Physician's Reports (LIC 602A) and the revised Needs and Services Plan, further supported staff's claims that changes in (R#1)'s condition were appropriately addressed.





During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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.




An exit interview was conducted, and a copy of the Complaint Report was given to Ashley Shire/Interim Executive Director

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6