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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 12/30/2025
Date Signed: 12/30/2025 12:29:10 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
12/19/2025 and conducted by Evaluator Zina Brown
COMPLAINT CONTROL NUMBER: 11-AS-20251219082509
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: DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Ashley Shire (Interim Executive Director) TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not report incidents to Community Care Licensing.
Due to staff neglect, resident sustained pressure injuries.
Staff do not ensure freezer temperatures are within range.
Staff served spoiled food to residents.
Staff do not follow physicians' orders.
INVESTIGATION FINDINGS:
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On 12/30/2025 at 10:49 am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings for the allegations above. During today's visit, LPA met with Ashley Shire (Interim Executive Director) and explained the purpose of the visit.

The investigation consisted of the following: On 12/23/2025 at 8:21am, Licensing Program Analyst (LPA) Zina Brown conducted interviews with Administrator (A1), Staff (S1-S6), and Residents (R1-R5) between 12:11pm - 1:56pm. R1 and R3 were unable to be interviewed due to communication barriers. LPA requested copies of Resident Roster (dated 12/16/2025), Staff Roster (dated 12/15/2025), Serious Incident Reports (dated 05/03/2025, 08/03/2025, 08/08/2025), refrigerator and freezer temperature check logs (for December 2025), Resident 3 (R3) records such as LIC 602 Physician Report for Residential Care Facilities for the Elderly (RCFE) (dated 07/20/2023), Service Plan (dated 09/19/2025), Outside Agency Documentation/Resident Notes for R3 dated 12/14/2025, 12/16/2025, 12/18/2025, 12/19/2025, and 12/22/2025, Resident 5 (R5) Outside Agency Documentation (dated 08/16/2025, 09/10/2025, 09/18/2025, 09/19/2025), AA Health Products Inc. for R5 (dated 09/22/2025), and LIC 601 Identification and Emergency Information (dated 12/14/2021 for R1, 12/15/2025 for R2, 07/19/2023 for R3, 03/07/2025 for R5).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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-20251219082509
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: 12/30/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Staff did not report incidents to Community Care Licensing
It was alleged that facility staff failed to report required incidents to Community Care Licensing, including resident injuries and other reportable events.

On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated any unusual incidents such as falls, injuries, abuse, hospice notification, etc., are always documented and submitted to the Department. The staff notify the nurse and medtech who contact first responders. Then a report is generated, and the facility nurse and or Administrator submits the report to Community Care Licensing.

On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation.
6 of 6 staff denied the allegation and stated that as mandated reporters, everything must be documented, such as any kind of abuse, falls, injuries, repairs, combative behavior between residents and/or staff, sickness, and/or illness, and must be reported to Community Care Licensing.

On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation.
5 of 5 residents denied the allegation. 2 of 5 residents stated staff come to help and explain if any incident occurs, while 3 of 5 residents stated not having any history of getting hurt and/or falling.

On 12/23/2025 at 11:55am, LPA interviewed R1's spouse Witness 2 (W2) by phone regarding it being alleged that R1 had a fall in the dining room in October 2025. W2 denied the allegation and stated it's possible due to R1 being non-ambulatory and using a geri-chair. W2 also mentioned the facility always notifies the family about everything pertaining to R1.

On 12/23/2025 between 2:30pm - 2:45pm, LPA conducted a record review and observed the following: The facility has a LIC 624 - Unusual Incident Reports (January 2025 - December 2025) binder which has the fax cover sheet as proof of faxing the Department of all the incidents that have occurred at the facility. Upon further review, the facility submitted an Unusual Incident/Injury Report regarding Resident 5 (R5) who had fallen but sustained no injuries, with medical doctor and power of attorney being notified. Also, on 08/08/2025, R5 had an unwitnessed fall in her room with some skin tear. First responders were called and transported R5 to the hospital.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20251219082509
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: 12/30/2025
NARRATIVE
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Allegation: Due to staff neglect, resident sustained pressure injuries
It was alleged that residents developed pressure injuries due to staff neglect.

On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated Resident 5 (R5) previously had a pressure injury around August 2025- September 2025. A1 also mentioned that R3 is the only resident at the facility who has a pressure injury, which is currently at the beginning stage and is receiving wound care from a Home Health Agency.

On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation.
2 of 6 staff neither confirmed nor denied the allegation and stated being aware of R3 having a pressure injury and wound care being provided by a home health agency. 4 of 6 staff were unaware of the allegation and stated not having knowledge of any residents who currently have a pressure injury.

On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation.
5 of 5 residents denied the allegation and stated not currently having a pressure injury.

On 12/23/2025 between 3:00pm - 3:10pm, LPA conducted a record review and observed the following: According to the Resident Notes (dated 12/14/2025 and 12/16/2025) for Resident 3 (R3), every three hours the staff check, clean, change, and apply Calazinc on the open wound in between the resident's buttocks, near the tailbone. On 12/18/2025 between 10:30pm - 5:30am, the staff checked on R3 and repositioned her on her left side and her right side every 3 hours. R3 is currently receiving wound care from Remedy Home Health (documentation dated 12/18/2025, 12/19/2025, and 12/22/2025). Resident 5 (R5) received wound care on 08/16/2025, 09/10/2025, 09/18/2025, and 09/19/2025, and as of 12/22/2025 does not have a pressure injury.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20251219082509
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: 12/30/2025
NARRATIVE
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Allegation: Staff do not ensure freezer temperatures are within range
It was alleged that staff failed to maintain freezer temperatures, which could cause food spoilage and unsafe meals.

On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated not having issues with food going bad, but if that was the case, spoiled food and unsafe meals would be thrown away. In the kitchen there are temperature logs for the bistro, refrigerator, and freezer. Also, A1 mentioned in the event of the freezer temperature falling outside of the required range, maintenance must be notified immediately. A1 said if the freezer temperature is found to be too warm or too cold, maintenance is notified, and food will be transferred to the deep freezer.

On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation.
4 of 6 staff denied the allegation and stated there have been no recent freezer temperatures out of range. Periodically the temperature for the bistro, refrigerator, and freezer are logged every day. However, if this is ever an issue, it is reported to maintenance and food will be removed and added to the deep freezer until the main freezer is repaired.
2 of 6 staff were unaware of the allegation and stated not having any knowledge of food spoilage and unsafe meals.

On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation.
5 of 5 residents denied the allegation and stated food usually appears to look okay and have not seen food look bad or spoiled.

On 12/23/2025 at 1:39pm, LPA conducted a tour of the kitchen and observed the following temperatures: 0°F (freezer), 37°F - 40°F (refrigerator), and 32°F (bistro).

On 12/24/2025 at 9:40am - 9:45am, LPA conducted a records review and observed the following: For the month of December from 12/1 - 12/23, the bistro measured between 28°F - 36°F, the refrigerator 32°F - 38°F, and the freezer 0°F - 3°F which is in compliance with Title 22 regulations.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20251219082509
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: 12/30/2025
NARRATIVE
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Allegation: Staff served spoiled food to residents
It was alleged that residents were served spoiled or unsafe food, posing a health risk.

On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated the facility has never served spoiled food to the residents, but if food appears spoiled, contaminated, or unsafe, it must first be reported and then thrown away. A1 also stated the process to follow before food is prepared and served to the residents is by following any special diets, special orders, allergies, and pureed food requirements.

On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation.
4 of 6 staff denied the allegation and stated there have been no recent incidents where residents were served spoiled food. However, if food ever appears spoiled, contaminated, or unsafe, food will be removed with the kitchen and the director being notified as well. 2 of 6 staff were unaware of the allegation and stated not having any knowledge of the staff serving spoiled food to the residents.

On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation.
5 of 5 residents denied the allegation and stated the meals given to the residents are breakfast, lunch, and dinner. Also, the food given to residents looks good and appears presentable.

On 12/23/2025 at 1:39pm, LPA conducted a tour of the kitchen and observed the following: perishable and non-perishable food supply was checked along with the refrigerator and freezer being fully stocked with a variety of food options in good condition.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20251219082509
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: 12/30/2025
NARRATIVE
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Allegation: Staff do not follow physician orders

It was alleged that staff failed to follow physician orders, including required health monitoring and treatments.
On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated the front desk, nurse, and medtech who have copies of physician orders are communicated with regarding medication alerts, allergies, and dietary requirements. A1 also stated if a special order is needed, the facility will ensure having the proper staff assist with the matter of following the physician's report.

On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation.
5 of 6 staff denied the allegation and stated the facility nurse and medtech communicate with the staff regarding what to be made aware of as it pertains to the residents. 1 of the staff mentioned typically outside agencies provide vital checks which are documented. One of 6 staff was unaware of the allegation and stated not having any knowledge regarding this due to being the lead cook of the facility.

On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation.
5 of 5 residents denied the allegation and stated blood pressure is not checked; however, the residents expressed that the facility always follows their physician orders.

On 12/23/2025 between 11:31am - 11:44am, LPA conducted an interview with Witness 1 (W1) regarding the allegation, and W1 stated an adjustment needs to be made by Resident 2's (R2) primary care physician, who would need to approve and update the medication list for the order of daily blood pressure checks to be conducted daily.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with Ashley Shire (Interim Executive Director), and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6